1
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Yuan Z, Levitan B, Deng H, Szarek M, Bauersachs RM, Berkowitz SD, Haskell L, Barnathan ES, Bonaca MP. Quantitative Benefit-Risk Evaluation of Rivaroxaban in Patients After Peripheral Arterial Revascularization: The VOYAGER PAD Trial. J Am Heart Assoc 2024; 13:e032782. [PMID: 38563380 DOI: 10.1161/jaha.123.032782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/02/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The VOYAGER PAD (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities) trial compared rivaroxaban (2.5 mg twice a day) plus aspirin with aspirin alone in patients with symptomatic peripheral artery disease requiring endovascular or surgical limb revascularization, with 50% receiving clopidogrel background therapy. The New Drug Indication application includes benefit-risk assessments using clinical judgment to balance benefits against risks. During its review, the US Food and Drug Administration requested additional quantitative benefit-risk analyses with formal weighting approaches. METHODS AND RESULTS Benefits and risks were assessed using rate differences between treatment groups (unweighted analysis). To account for clinical importance of the end points, a multi-criteria decision analysis was conducted using health state utility values as weights. Monte Carlo simulations incorporated statistical uncertainties of the event rates and utility weights. Intent-to-treat and on-treatment analyses were conducted. For unweighted intent-to-treat analyses, rivaroxaban plus aspirin would result in 120 (95% CI, -208 to -32) fewer events of the primary composite end point (per 10 000 patient-years) compared with aspirin alone. Rivaroxaban caused an excess of 40 (95% CI, 8-72) Thrombolysis in Myocardial Infarction major bleeding events, which was largely driven by nonfatal, nonintracranial hemorrhage Thrombolysis in Myocardial Infarction major bleeding events. For weighted analyses, rivaroxaban resulted in the utility equivalent of 13.7 (95% CI, -85.3 to 52.6) and 68.1 (95% CI, 7.9-135.7) fewer deaths per 10 000 patient-years (intent-to-treat and on-treatment, respectively), corresponding to probabilities of 64.4% and 98.7%, respectively, that benefits outweigh risks favoring rivaroxaban per Monte Carlo simulation. CONCLUSIONS These analyses show a favorable benefit-risk profile of rivaroxaban therapy in the VOYAGER PAD trial, with findings generally consistent between the unweighted and weighted approaches.
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Affiliation(s)
- Zhong Yuan
- Janssen Research & Development LLC Horsham PA
| | | | | | - Michael Szarek
- CPC Clinical Research, Department of Medicine University of Colorado Aurora CO
| | - Rupert M Bauersachs
- Cardioangiologisches Centrum Bethanien - CCB Gefäß-Centrum Frankfurt am Main Germany
| | - Scott D Berkowitz
- CPC Clinical Research, Department of Medicine University of Colorado Aurora CO
| | | | | | - Marc P Bonaca
- CPC Clinical Research, Department of Medicine University of Colorado Aurora CO
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2
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Hsia J, Spyropoulos AC, Piazza G, Weng S, Dunne MW, Lipardi C, Barnathan ES, Bonaca MP. Antithrombotic Prophylaxis with Rivaroxaban in Patients with Prehospital COVID-19: A Meta-analysis of Two Placebo-Controlled Trials. Thromb Haemost 2023. [PMID: 37995748 DOI: 10.1055/a-2216-5848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND We conducted a prespecified meta-analysis of two randomized, placebo-controlled trials of rivaroxaban 10 mg daily in prehospital patients with acute coronavirus disease 2019 (COVID-19). Individually, the trials had limited power to detect a treatment effect due to recruitment stopping ahead of plan. MATERIAL AND METHODS The statistical analysis plan for the meta-analysis was finalized before unblinding of PREVENT-HD, the larger of the two trials. Pooled risk ratios and pooled risk differences along with the two-sided 95% confidence intervals were calculated using random-effect models. RESULTS Rivaroxaban did not reduce the occurrence of either the primary prespecified endpoint, a composite of symptomatic arterial and venous thromboembolism, myocardial infarction, ischemic stroke, acute limb ischemia, all-cause hospitalization, and all-cause mortality (risk difference: 0.0044; 95% confidence interval: -0.0263, 0.0175; p = 0.69 for pooled risk difference) or the secondary endpoint of all-cause hospitalization (p = 0.76). Although thrombotic events were infrequent, pooled analysis did reveal that rivaroxaban reduced arterial and venous thrombotic events (placebo 6 events, rivaroxaban 0 events; pooled risk difference: -0.0068; 95% confidence interval: -0.0132, -0.0006; p = 0.03). In the pooled studies, only one major bleeding event was observed in a rivaroxaban-allocated patient with no critical site or fatal bleeding events. CONCLUSION Although this meta-analysis does not support antithrombotic prophylaxis with rivaroxaban in a broad prehospital population with acute COVID-19, the prevention of arterial and venous thrombotic events among rivaroxaban-allocated patients is consistent with the known thromboprophylactic effect of the drug in medically ill patients.
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Affiliation(s)
- Judith Hsia
- Colorado Prevention Center and Department of Medicine, University of Colorado, Aurora, Colorado, United States
| | - Alex C Spyropoulos
- Feinstein Institutes for Medical Research and Department of Medicine, Northwell Health, New York, New York, United States
| | - Gregory Piazza
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Stephen Weng
- Janssen Research and Development, Statistical Decision Sciences, Cardiovascular and Metabolism, High Wycombe, United Kingdom
| | - Michael W Dunne
- Bill and Melinda Gates Medical Research Institute, Cambridge, Massachusetts, United States
| | - Concetta Lipardi
- Janssen Research and Development, Clinical Development, Raritan, New Jersey, United States
| | - Elliot S Barnathan
- Janssen Research and Development, Clinical Development, Raritan, New Jersey, United States
| | - Marc P Bonaca
- Colorado Prevention Center and Department of Medicine, University of Colorado, Aurora, Colorado, United States
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3
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Piazza G, Spyropoulos AC, Hsia J, Goldin M, Towner WJ, Go AS, Bull TM, Weng S, Lipardi C, Barnathan ES, Bonaca MP. Rivaroxaban for Prevention of Thrombotic Events, Hospitalization, and Death in Outpatients With COVID-19: A Randomized Clinical Trial. Circulation 2023. [PMID: 37154020 DOI: 10.1161/circulationaha.123.063901] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND COVID-19 (coronavirus disease 2019) is associated with heightened risks of venous and arterial thrombosis and hospitalization due to respiratory failure. To assess whether prophylactic anticoagulation can safely reduce the frequency of venous and arterial thrombosis, hospitalization, and death in nonhospitalized patients with symptomatic COVID-19 and at least one thrombosis risk factor, we conducted the PREVENT-HD double-blind, placebo-controlled randomized trial (A Study of Rivaroxaban to Reduce the Risk of Major Venous and Arterial Thrombotic Events, Hospitalization and Death in Medically Ill Outpatients With Acute, Symptomatic COVID-19] Infection). METHODS PREVENT-HD was conducted between August 2020 and April 2022 at 14 US integrated health care delivery networks. A virtual trial design used remote informed consent and clinical monitoring and facilitated data collection through electronic health record integration with a cloud-based research platform. Nonhospitalized patients with symptomatic COVID-19 and at least one thrombosis risk factor were enrolled and randomly assigned to either 10 mg of oral rivaroxaban or placebo daily for 35 days. The primary efficacy outcome was time to first occurrence of a composite of symptomatic venous thromboembolism, myocardial infarction, ischemic stroke, acute limb ischemia, non-central nervous system systemic arterial embolism, hospitalization, or death through day 35. The principal safety end point was International Society on Thrombosis and Hemostasis critical-site or fatal bleeding. The last study visit was on day 49. RESULTS The study was terminated prematurely because of enrollment challenges and a lower-than-expected blinded pooled event rate. A total of 1284 patients underwent randomization with complete accrual of primary events through May 2022. No patients were lost to follow-up. The primary efficacy outcome occurred in 22 of 641 in the rivaroxaban group and 19 of 643 in the placebo group (3.4% versus 3.0%; hazard ratio, 1.16 [95% CI, 0.63-2.15]; P=0.63). No patient in either group experienced critical-site or fatal bleeding. One patient receiving rivaroxaban had a major bleed. CONCLUSIONS The study was terminated prematurely after enrollment of 32% of planned accrual because of recruitment challenges and lower-than-expected event rate. Rivaroxaban prescribed for 35 days in nonhospitalized patients with symptomatic COVID-19 at risk for thrombosis did not appear to reduce a composite end point of venous and arterial thrombotic events, hospitalization, and death. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04508023.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.P.)
| | - Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research (A.C.S., M.G.), Northwell Health, Manhasset, NY
- Anticoagulation and Clinical Thrombosis Service (A.C.S.), Northwell Health, Manhasset, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (A.C.S.)
| | - Judith Hsia
- Colorado Prevention Center Clinical Research, Aurora, CO (J.H., M.P.B.)
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (J.H., M.P.B.)
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research (A.C.S., M.G.), Northwell Health, Manhasset, NY
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (M.G.)
| | - William J Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (W.J.T.)
- Department of Infectious Disease, Kaiser Permanente Los Angeles Medical Center, CA (W.J.T.)
- Departments of Clinical Science (W.J.T.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Alan S Go
- Health Systems Science (A.S.G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco (A.S.G.)
| | - Todd M Bull
- Pulmonary Sciences and Critical Care Medicine and Cardiology, University of Colorado School of Medicine, Aurora (T.M.B.)
| | - Stephen Weng
- Janssen Research and Development, Statistical Decision Sciences, Cardiovascular and Metabolism, High Wycombe, UK (S.W.)
| | - Concetta Lipardi
- Janssen Research and Development, Clinical Development, Raritan, NJ (C.L., E.S.B.)
| | - Elliot S Barnathan
- Janssen Research and Development, Clinical Development, Raritan, NJ (C.L., E.S.B.)
| | - Marc P Bonaca
- Colorado Prevention Center Clinical Research, Aurora, CO (J.H., M.P.B.)
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (J.H., M.P.B.)
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4
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Volkl AA, Moore KT, Haskell L, Barnathan ES. Updated Renal Dosage Recommendations for Rivaroxaban in Patients Experiencing or at Risk of Thromboembolic Disease. Am J Cardiovasc Drugs 2023; 23:247-255. [PMID: 37115488 PMCID: PMC10164019 DOI: 10.1007/s40256-023-00579-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/29/2023]
Abstract
Patients with chronic kidney disease are at an increased risk of venous thromboembolism (VTE). The factor Xa inhibitor rivaroxaban has been shown to provide similar efficacy and a lower risk of bleeding compared with vitamin K antagonists for the treatment and prevention of VTE. Rivaroxaban has been studied in patients with varying degrees of renal impairment, and this review summarizes current knowledge supporting its use in patients with severe renal impairment (creatinine clearance [CrCl] of 15 to < 30 mL/min) for the prevention, treatment, or prophylaxis of VTE. Clinical pharmacology studies have demonstrated an increase in rivaroxaban systemic exposure, factor Xa inhibition, and prothrombin time with decreasing renal function. These changes reach a plateau with comparable increases in exposure among individuals with moderate or severe renal impairment and end-stage renal disease. The clinical development program for the treatment and prevention of VTE as well as prophylaxis of deep vein thrombosis (DVT) following orthopedic surgery excluded patients with CrCl < 30 mL/min; however, a limited number of patients with severe renal impairment were enrolled. Efficacy outcomes in these patients with severe renal impairment were not meaningfully different from those of patients with higher levels of renal function. There was also no increase in the incidence of major bleeding with rivaroxaban in patients with CrCl < 30 mL/min. Taken together, these pharmacological and clinical data suggest that in patients with severe renal impairment, the approved dosages of rivaroxaban can be used in the treatment and prevention of VTE and for prophylaxis of DVT after hip or knee replacement surgery.
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Affiliation(s)
- Albert A Volkl
- Janssen Pharmaceuticals, Inc, 1125 Trenton Harbourton Rd, Titusville, NJ, 08560, USA.
| | - Kenneth Todd Moore
- Janssen Pharmaceuticals, Inc, 1125 Trenton Harbourton Rd, Titusville, NJ, 08560, USA
| | - Lloyd Haskell
- Janssen Research & Development, LLC, Raritan, NJ, USA
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5
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Raskob GE, Ageno W, Albers G, Elliott CG, Halperin J, Maynard G, Steg PG, Weitz JI, Albanese J, Yuan Z, Levitan B, Lu W, Suh EY, Spiro T, Lipardi C, Barnathan ES, Spyropoulos AC. Benefit-Risk Assessment of Rivaroxaban for Extended Thromboprophylaxis After Hospitalization for Medical Illness. J Am Heart Assoc 2022; 11:e026229. [PMID: 36205248 DOI: 10.1161/jaha.122.026229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Venous thromboembolism (VTE) often occurs after hospitalization in medically ill patients, but the population benefit-risk of extended thromboprophylaxis remains uncertain. Methods and Results The MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) study (NCT02111564) was a randomized double-blind trial that compared thromboprophylaxis with rivaroxaban 10 mg daily versus placebo for 45 days after hospital discharge in medically ill patients with a creatinine clearance ≥50 mL/min. The benefit-risk balance in this population was quantified by calculating the between-treatment rate differences in efficacy and safety end points per 10 000 patients treated. Clinical characteristics of the study population were consistent with a hospitalized medical population at risk for VTE. Treating 10 000 patients with rivaroxaban resulted in 32.5 fewer symptomatic VTE and VTE-related deaths but was associated with 8 additional major bleeding events. The treatment benefit was driven by the prevention of nonfatal symptomatic VTE (26 fewer events). There was no between-treatment difference in the composite of critical site or fatal bleeding. Conclusions Extending thromboprophylaxis with rivaroxaban for 45 days after hospitalization provides a positive benefit-risk balance in medically ill patients at risk for VTE who are not at high risk for bleeding. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT02111564.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | - Gregory Albers
- Stanford Stroke Center Stanford University Medical Center Stanford CA
| | - C Gregory Elliott
- Department of Medicine Intermountain Medical Center and the University of Utah Salt Lake City UT
| | | | | | - Philippe Gabriel Steg
- Universite Paris-Cite Assistance Publique-Hôpitauxde Paris, and INSERM U-1148 Paris France.,Imperial College, Royal Brompton Hospital London United Kingdom
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | | | - Zhong Yuan
- Janssen Research & Development, LLC Titusville NJ
| | | | - Wentao Lu
- Janssen Research & Development, LLC Raritan NJ
| | | | - Theodore Spiro
- Clinical Development Pharmaceuticals, Bayer U.S. LLC Whippany NJ
| | | | | | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell The Feinstein Institute for Medical Research, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lennox Hill Hospital New York NY
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6
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Spyropoulos AC, Goldin M, Ageno W, Albers GW, Elliott CG, Hiatt WR, Halperin JL, Maynard G, Steg PG, Weitz JI, Spiro TE, Lu W, Marsigliano J, Raskob GE, Barnathan ES. Rivaroxaban Plus Aspirin for Extended Thromboprophylaxis in Acutely Ill Medical Patients: Insights from the MARINER Trial. TH Open 2022; 6:e177-e183. [PMID: 36046208 PMCID: PMC9273326 DOI: 10.1055/s-0042-1750379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
The MARINER trial evaluated whether postdischarge thromboprophylaxis with rivaroxaban could reduce the primary outcome of symptomatic venous thromboembolism (VTE) or VTE-related death in acutely ill medical patients at risk for VTE. Although aspirin use was not randomized, approximately half of the enrolled patients were receiving aspirin at baseline. We hypothesized that thromboprophylaxis with once-daily rivaroxaban (10 mg or, if creatinine clearance was 30–49 mL/min, 7.5 mg) plus aspirin (R/A) would be superior to placebo without aspirin (no thromboprophylaxis [no TP]).
Methods
We compared the primary and major secondary outcomes in the intention-to-treat population in four subgroups defined at baseline: (1) R/A (
N
= 3,159); (2) rivaroxaban alone (
N
= 2,848); (3) aspirin alone (
N
= 3,046); and (4) no TP (
N
= 2,966). Major bleeding (MB) and nonmajor clinically relevant (NMCR) bleeding were assessed in the safety population on treatment plus 2 days.
Results
Patients on R/A had reduced symptomatic VTE and VTE-related death compared with no TP (0.76 vs 1.28%,
p
= 0.042), and experienced less symptomatic VTE and all-cause mortality (
p
= 0.005) and all-cause mortality alone (
p
= 0.01) compared with no TP. Event incidences for rivaroxaban alone (0.91%) or aspirin alone (0.92%) were similar. MB was low in all groups but lowest in the no TP group. NMCR bleeding was increased with R/A compared with no TP (
p
= 0.009).
Limitations
Aspirin use was not randomized.
Conclusion
Extended postdischarge thromboprophylaxis with R/A was associated with less symptomatic VTE and VTE-related death compared with no TP in previously hospitalized medical patients at risk for VTE. NMCR bleeding was increased with R/A compared with no TP. These post hoc findings need confirmation in a prospective trial.
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Affiliation(s)
- Alex C. Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, New York, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
| | - Mark Goldin
- Northwell Health, Great Neck, New York, United States
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- University of Insubria, Varese, Italy
| | - Gregory W. Albers
- Stanford Stroke Center, Stanford Medical Center, Stanford University, Palo Alto, California, United States
| | - C. Gregory Elliott
- Department of Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, United States
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine
- CPC Clinical Research, Aurora, Colorado, United States
| | - Jonathan L. Halperin
- Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, United States
| | - Gregory Maynard
- University of California at Davis, Sacramento, California, United States
| | - P. Gabriel Steg
- Université de Paris, Assistance Publique–Hôpitaux de Paris, and INSERM U-1148, Paris, France
| | - Jeffrey I. Weitz
- McMaster University
- The Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | - Wentao Lu
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
| | - Jessica Marsigliano
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
| | - Gary E. Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Elliot S. Barnathan
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
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7
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Spyropoulos AC, Raskob GE, Cohen AT, Ageno W, Weitz JI, Spiro TE, Lu W, Lipardi C, Albers GW, Elliott CG, Halperin JL, Hiatt WR, Maynard G, Steg PG, Sugarmann C, Barnathan ES. Association of Bleeding Severity with Mortality in Extended Thromboprophylaxis of Medically Ill Patients in the MAGELLAN and MARINER Trials. Circulation 2022; 145:1471-1479. [PMID: 35389229 DOI: 10.1161/circulationaha.121.057847] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Extended thromboprophylaxis has not been widely implemented in acutely ill medical patients due to bleeding concerns. The MAGELLAN and MARINER trials evaluated whether rivaroxaban compared with enoxaparin or placebo could prevent venous thromboembolism (VTE) without increased bleeding. We hypothesized that patients with major bleeding (MB) but not those with non-major clinically relevant bleeding (NMCRB), would be at an increased risk of all-cause mortality (ACM). Methods: We evaluated all bleeding events in patients taking at least one dose of study drug and their association with ACM in 4 mutually exclusive groups: (1) no bleeding, or first event was (2) NMCRB, (3) MB, or (4) trivial bleeding. Using a Cox proportional hazards model adjusted for differences in baseline characteristics associated with ACM, we assessed the risk of ACM after such events. Results: Compared to patients with no bleeding, the risk of ACM for patients with NMCRB was not increased in MARINER (HR 0.43, p=0.235) but was increased in MAGELLAN (HR 1.74 p=0.021). MB was associated with a higher incidence of ACM in both studies, while trivial bleeding was not associated with ACM in either study. Conclusions: Patients with MB had an increased risk of ACM, while NMCRB was not consistently associated with an increased risk of death. These results inform the risk-benefit calculus of extended thromboprophylaxis in medically ill patients.
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Affiliation(s)
- Alex C Spyropoulos
- The Feinstein Institute for Medical Research, Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Gary E Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Alexander T Cohen
- Department of Hematological Medicine, Guys and St Thomas/NHS Foundation Trust, King's College London, London, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy and University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Wentao Lu
- Biostatistics Department, Janssen Research and Development LLC, Raritan, NJ
| | - Concetta Lipardi
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Gregory W Albers
- Director Stanford Stroke Center, Stanford Medical Center, Stanford University, Palo Alto, CA
| | - C Gregory Elliott
- Departments of Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | | | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO
| | | | - P Gabriel Steg
- Université de Paris, INSERM UMR-1148 F- 75018 Paris, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Chiara Sugarmann
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Elliot S Barnathan
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
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Harman NL, Gorst SL, Williamson PR, Barnathan ES, Baughman RP, Judson MA, Junk H, Kampstra NA, Sullivan EJ, Victorson DE, Walton MK, AL-Hakim T, Nabulsi H, Singh N, Grutters JC, Culver DA. Identifying a core outcome set for pulmonary sarcoidosis research - the Foundation for Sarcoidosis Research - Sarcoidosis Clinical OUtcomes Taskforce (SCOUT). Sarcoidosis Vasc Diffuse Lung Dis 2022; 39:e2022030. [PMID: 36791046 PMCID: PMC9766848 DOI: 10.36141/svdld.v39i3.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 07/13/2022] [Indexed: 02/16/2023]
Abstract
Background Pulmonary sarcoidosis is a rare granulomatous disease of unknown aetiology. Heterogeneity in the outcomes measured in trials of treatment for pulmonary sarcoidosis has impacted on the ability to systematically compare findings, contributing to research inefficiency. The FSR-SCOUT study has aimed to address this heterogeneity by developing a core outcome set that represents a patient and health professional consensus on the most important outcomes to measure in future research for the treatment of pulmonary sarcoidosis. Research design and methods systematic review of trial registries, narrative synthesis of published qualitative literature on the patient experience and results of a patient survey contributed to the development of a comprehensive list of outcomes that were rated in a two round online Delphi survey. The Delphi survey was completed by patients/carers and health professionals and the results discussed and ratified at an online consensus meeting. Results 259 patients/carers and 51 health professionals completed both rounds of the Delphi survey. A pre-agreed definition of consensus was applied and the results discussed at an online consensus meeting attended by 17 patients and 7 health professionals). Fifteen outcomes, across five domains (physiological/clinical, treatment, resource use, quality of life, and death), reached the definition of consensus and were included in the core outcome set. Conclusions The core outcome set represents a patient and health professional consensus on the most important outcomes for pulmonary sarcoidosis research. The use of the core outcome set in future trials, and efforts to validate its components, will enhance the relevance of trials to stakeholders and will increase the opportunity for the research to contribute to evidence synthesis.
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Affiliation(s)
- Nicola L. Harman
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sarah L. Gorst
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | | | - Robert P. Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Marc A. Judson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York, USA
| | - Heidi Junk
- Patient Advocate – Foundation for Sarcoidosis Research
| | - Nynke A. Kampstra
- Dept of Value-Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands, Interstitial Lung Diseases Centre of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | - Hana Nabulsi
- The Foundation for Sarcoidosis Research, Chicago, IL, USA
| | - Noopur Singh
- The Foundation for Sarcoidosis Research, Chicago, IL, USA
| | - Jan C. Grutters
- Interstitial Lung Diseases Centre of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands, Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel A. Culver
- Department of Pulmonary, Medicine, Respiratory Institute, at Cleveland Clinic, Cleveland, OH, USA
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9
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Raskob GE, Spyropoulos AC, Spiro TE, Lu W, Yuan Z, Levitan B, Suh E, Barnathan ES. Benefit-Risk of Rivaroxaban for Extended Thromboprophylaxis After Hospitalization for Medical Illness: Pooled Analysis From MAGELLAN and MARINER. J Am Heart Assoc 2021; 10:e021579. [PMID: 34755519 PMCID: PMC8751917 DOI: 10.1161/jaha.121.021579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Thromboprophylaxis extended after hospital discharge in medically ill patients currently is not recommended by practice guidelines because of uncertainty about the benefit for preventing major or fatal thromboembolic events, and the risk of bleeding. Methods and Results We assessed the benefit and risk of thromboprophylaxis with rivaroxaban 10 mg once daily extended for 25 to 45 days after hospitalization for preventing major thromboembolism in medically ill patients using the pooled data in 16 496 patients from 2 randomized trials, MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post‐Discharge Venous Thrombo‐Embolism Risk) and MAGELLAN (Multicenter, randomized, parallel‐group efficacy and safety study for the prevention of venous thromboembolism in hospitalized medically ill patients comparing rivaroxaban with enoxaparin). The data from the MARINER trial were pooled with the data from the MAGELLAN trial in patients who were free of thrombotic or bleeding events up to the last dose of enoxaparin/placebo and who continued in the outpatient phase of thromboprophylaxis. The composite outcome of major thromboembolic events (symptomatic deep vein thrombosis, nonfatal pulmonary embolism, myocardial infarction, and nonhemorrhagic stroke) and all‐cause mortality was used to assess benefit and was compared with the risk of the composite of fatal and critical site bleeding. The incidence of the composite efficacy outcome was 1.80% (148 of 8222 patients) in the rivaroxaban group, compared with 2.31% (191 of 8274 patients in the placebo group) (HR, 0.78 [95% CI, 0.63–0.97], P=0.024). Fatal or critical site bleeding events were infrequent and occurred in <0.1% of patients in both groups (rivaroxaban 0.09%; placebo 0.04%; HR, 2.36; P=0.214). Conclusions The results suggest a benefit for reducing major thromboembolic outcomes (number needed to treat: 197), with a favorable trade‐off to fatal or critical site bleeding (number needed to harm: 2045). Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00571649 and NCT02111564.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City OK
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill HospitalThe Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research New York NY.,Department of Obstetrics and Gynecology I.M. Sechenov First Moscow State Medical University Moscow Russia
| | - Theodore E Spiro
- Thrombosis and Hematology Therapeutic Area Clinical Development Pharmaceuticals Bayer U.S. LLC Whippany NJ
| | - Wentao Lu
- Janssen Research and Development LLC Raritan NJ
| | - Zhong Yuan
- Janssen Research and Development LLC Titusville NJ
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10
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Harman NL, Gorst SL, Williamson PR, Barnathan ES, Baughman RP, Judson MA, Junk H, Kampstra NA, Sullivan EJ, Victorson DE, Walton M, Al-Hakim T, Nabulsi H, Singh N, Grutters JC, Culver DA. Scout - sarcoidosis outcomes taskforce. A systematic review of outcomes to inform the development of a core outcome set for pulmonary sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2021; 38:e2021034. [PMID: 34744426 PMCID: PMC8552570 DOI: 10.36141/svdld.v38i3.10737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Background: Clinical trials evaluating different management strategies for pulmonary sarcoidosis may measure different outcomes. This heterogeneity in outcomes can lead to waste in research due to the inability to compare and combine data. Core outcome sets (COS) have the potential to address this issue and here we describe a systematic review of outcomes as the first step in the development of a COS for pulmonary sarcoidosis research. Methods: A search of clinical trial registries for phase II, III and IV trials of pulmonary sarcoidosis was undertaken along with a rapid review of the patient perspective literature. Each study was screened for eligibility and outcomes extracted verbatim from the registry entry or publication then reviewed, grouped and categorised using the COMET taxonomy. Results: 36 trial registry entries and 6 studies on patients’ perspective of pulmonary sarcoidosis were included reporting 56 and 82 unique outcomes respectively across 23 domains. The most frequently reported outcome domain was “respiratory, thoracic and mediastinal outcomes”. However, the patients’ perspective literature identified outcomes in the “personal circumstances” and “societal/carer burden” domains that were not reported in any of the included trial registrations. Conclusions: Using both clinical trial registry data and published literature on patients’ perspective has allowed rapid review of outcomes measured and reported in pulmonary sarcoidosis research. The use of multiple sources has led to the development of a comprehensive list of outcomes that represents the first step in the development of a COS for use in future pulmonary sarcoidosis research.
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Affiliation(s)
- Nicola L Harman
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sarah L Gorst
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Paula R Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Marc A Judson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York, USA
| | - Heidi Junk
- Patient Advocate - Foundation for Sarcoidosis Research
| | - Nynke A Kampstra
- Dept of Value-Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands.,The Foundation for Sarcoidosis Research, Chicago, Illinois, USA
| | - Eugene J Sullivan
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | | | - Marc Walton
- Northwestern University Feinberg School of Medicine, Evanston, IL, USA
| | | | - Hana Nabulsi
- Janssen Research and Development, Titusville, NJ, USA
| | - Noopur Singh
- Janssen Research and Development, Titusville, NJ, USA
| | - Jan C Grutters
- The Foundation for Sarcoidosis Research, Chicago, Illinois, USA.,Interstitial Lung Diseases Centre of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Daniel A Culver
- Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
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11
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Lipardi C, Elliott CG, Sugarmann CL, Haskell L, Spyropoulos AC, Raskob GE, Xu J, Lu W, Marsigliano J, Spiro T, Yuan Z, Wu S, Barnathan ES. Risk of Severe Bleeding With Extended Rivaroxaban to Prevent Venous Thromboembolism in Acute Medically Ill Patients With Bronchiectasis. Clin Appl Thromb Hemost 2021; 27:10760296211053316. [PMID: 34719984 PMCID: PMC8559236 DOI: 10.1177/10760296211053316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Bronchiectasis is a chronic inflammation of the bronchi with recurrent infections and hemoptysis. The MAGELLAN study compared oral rivaroxaban, 10 mg once daily (QD), for 35 ± 4 days with subcutaneous enoxaparin 40 mg QD for 10 ± 4 days followed by placebo for 25 ± 4 days to prevent venous thromboembolism in patients hospitalized with an acute medical illness. MAGELLAN included a subset of patients with bronchiectasis. In a post hoc analysis, we evaluated the incidence and severity of pulmonary bleeding in patients with bronchiectasis who were hospitalized for an acute medical illness. This analysis included MAGELLAN patients diagnosed with bronchiectasis at baseline. Patients were evaluated by treatment group for International Society on Thrombosis and Haemostasis major bleeding, non-major clinically relevant (NMCR) bleeding, and the composite of the 2 (ie, clinically relevant bleeding). Results: Medically ill patients with bronchiectasis were randomized to rivaroxaban (n = 60) or enoxaparin/placebo (n = 61). There were 2 fatal pulmonary bleeds and 1 fatal gastrointestinal bleed in the rivaroxaban arm and no fatal or major bleeding in the enoxaparin/placebo arm. The incidence of major bleeding was 5% in the rivaroxaban arm. One NMCR bleed occurred in the rivaroxaban arm and 2 NMCR bleeds occurred in the enoxaparin/placebo arm. The incidence of clinically relevant bleeding was 6.7% versus 3.3% in the rivaroxaban and enoxaparin/placebo groups, respectively (relative risk = 2.06 [95% confidence interval: 0.351-12.046]). Conclusion: In-patients hospitalized with bronchiectasis and an acute medical illness, clinically relevant bleeding, including fatal pulmonary hemorrhage, occurs more frequently with extended rivaroxaban thromboprophylaxis than with enoxaparin followed by placebo.
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Affiliation(s)
| | | | | | - Lloyd Haskell
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | - Alex C Spyropoulos
- 232890The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA.,68477I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Gary E Raskob
- Hudson College of Public Health, 51166University of Oklahoma Health Sciences Center, OK, USA
| | - Jianfeng Xu
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | | | | | - Zhong Yuan
- 6808Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Shujian Wu
- 6808Janssen Research and Development, LLC, Horsham, PA, USA
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12
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Ageno W, Lopes RD, Goldin M, Yusen RD, Albers GW, Elliott GC, Halperin JL, Hiatt WR, Maynard G, Steg PG, Weitz JI, Suh E, Lu W, Barnathan ES, Raskob GE, Spyropoulos AC. Rivaroxaban for extended thromboprophylaxis in acutely ill medical patients 75 years of age or older. J Thromb Haemost 2021; 19:2772-2780. [PMID: 34314574 PMCID: PMC9292378 DOI: 10.1111/jth.15477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/07/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although older patients are at increased risk for venous thromboembolism (VTE), thromboprophylaxis is underused because of bleeding concerns. The MARINER trial evaluated whether rivaroxaban reduced symptomatic postdischarge VTE in acutely ill medical patients. OBJECTIVES We hypothesized that rivaroxaban would have a favorable benefit/risk profile in patients ≥75 years of age. METHODS Patients were randomized in a double-blind manner at hospital discharge to rivaroxaban (10 mg/day for creatinine clearance ≥50 ml/min; 7.5 mg/day for ≥30-<50 ml/min) or placebo for 45 days. Using a Cox proportional hazard model including treatment as a covariate, we compared the risk of the primary efficacy outcome (symptomatic VTE plus VTE-related death in the intention-to-treat population) and safety outcome (International Society on Thrombosis and Haemostasis major bleeding in the safety population) in the prespecified subgroups of patients ≥ and <75 years of age. RESULTS The primary event rate in patients ≥75 years of age was 2-fold higher than that in those <75 years. The incidence of the primary efficacy outcomes in both age groups was numerically lower with rivaroxaban than with placebo (≥75: 1.2% and 1.6%, HR 0.73, 95% CI 0.43-1.22; <75 0.6% and 0.8%, HR 0.78, 95% CI 0.46-1.32; interaction p-value for age group = .85). The incidence of major bleeding was low and similar in the two age and treatment groups (interaction p value for age group = .35). CONCLUSION Symptomatic VTE and VTE-related death occur frequently in older patients with acute medical illness. The benefit/risk profile of rivaroxaban in patients ≥75 years of age appears consistent with that observed in the general population.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | - Renato D. Lopes
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNCUSA
| | - Mark Goldin
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill HospitalThe Feinstein Institute for Medical Research and Zucker School of Medicine at Hofstra/NorthwellNew YorkNYUSA
| | - Roger D. Yusen
- Division of Pulmonary and Critical Care MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Gregory W. Albers
- Director Stanford Stroke CenterStanford Medical CenterStanford UniversityPalo AltoCAUSA
| | - Gregory C. Elliott
- Departments of MedicineUniversity of Utah and Intermountain HealthcareSalt Lake CityUTUSA
| | | | - William R. Hiatt
- Division of CardiologyUniversity of Colorado School of Medicine, and CPC Clinical ResearchAuroraCOUSA
| | | | | | - Jeffrey I. Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research InstituteHamiltonONCanada
| | - Eunyoung Suh
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Wentao Lu
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Elliot S. Barnathan
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Gary E. Raskob
- Hudson College of Public HealthThe University of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Alex C. Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill HospitalThe Feinstein Institute for Medical Research and Zucker School of Medicine at Hofstra/NorthwellNew YorkNYUSA
- Department of Obstetrics and GynecologyI.M. Sechenov First Moscow State Medical UniversityMoscowRussia
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13
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Capell WH, Barnathan ES, Piazza G, Spyropoulos AC, Hsia J, Bull S, Lipardi C, Sugarmann C, Suh E, Rao JP, Hiatt WR, Bonaca MP. Rationale and design for the study of rivaroxaban to reduce thrombotic events, hospitalization and death in outpatients with COVID-19: The PREVENT-HD study. Am Heart J 2021; 235:12-23. [PMID: 33577800 PMCID: PMC7871775 DOI: 10.1016/j.ahj.2021.02.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/01/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND COVID-19 is associated with both venous and arterial thrombotic complications. While prophylactic anticoagulation is now widely recommended for hospitalized patients with COVID-19, the effectiveness and safety of thromboprophylaxis in outpatients with COVID-19 has not been established. STUDY DESIGN PREVENT-HD is a double-blind, placebo-controlled, pragmatic, event-driven phase 3 trial to evaluate the efficacy and safety of rivaroxaban in symptomatic outpatients with laboratory-confirmed COVID-19 at risk for thrombotic events, hospitalization, and death. Several challenges posed by the pandemic have necessitated innovative approaches to clinical trial design, start-up, and conduct. Participants are randomized in a 1:1 ratio, stratified by time from COVID-19 confirmation, to either rivaroxaban 10 mg once daily or placebo for 35 days. The primary efficacy end point is a composite of symptomatic venous thromboembolism, myocardial infarction, ischemic stroke, acute limb ischemia, non-central nervous system systemic embolization, all-cause hospitalization, and all-cause mortality. The primary safety end point is fatal and critical site bleeding according to the International Society on Thrombosis and Haemostasis definition. Enrollment began in August 2020 and is expected to enroll approximately 4,000 participants to yield the required number of end point events. CONCLUSIONS PREVENT-HD is a pragmatic trial evaluating the efficacy and safety of the direct oral anticoagulant rivaroxaban in the outpatient setting to reduce major venous and arterial thrombotic events, hospitalization, and mortality associated with COVID-19.
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Affiliation(s)
- Warren H Capell
- CPC Clinical Research, Aurora, CO; Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | | | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alex C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Huntington, NY; Institute for Health Innovation and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Scott Bull
- Janssen Research and Development LLC, Raritan, NJ
| | | | | | - Eunyoung Suh
- Janssen Research and Development LLC, Raritan, NJ
| | | | - William R Hiatt
- CPC Clinical Research, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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14
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Raskob GE, Spyropoulos AC, Cohen AT, Weitz JI, Ageno W, De Sanctis Y, Lu W, Xu J, Albanese J, Sugarmann C, Weber T, Lipardi C, Spiro TE, Barnathan ES. Association Between Asymptomatic Proximal Deep Vein Thrombosis and Mortality in Acutely Ill Medical Patients. J Am Heart Assoc 2021; 10:e019459. [PMID: 33586478 PMCID: PMC8174250 DOI: 10.1161/jaha.120.019459] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Asymptomatic proximal deep vein thrombosis (DVT) is an end point frequently used to evaluate the efficacy of anticoagulant thromboprophylaxis in medical patients. Recently, the clinical relevance of asymptomatic DVT has been challenged. Methods and Results The objective of this study was to evaluate the relationship between asymptomatic proximal DVT and all-cause mortality (ACM) using a cohort analysis of a randomized trial for the prevention of venous thromboembolism (VTE) in acutely ill medical patients. Patients who received at least 1 dose of study drug and had an adequate compression ultrasound examination of the legs on either day 10 or day 35 were categorized into 1 of 3 cohorts: no VTE, asymptomatic proximal DVT, or symptomatic DVT. Cox proportional hazards model, with adjustment for significant independent predictors of mortality, were used to compare the incidences of ACM. Of the 7036 patients, 6776 had no VTE, 236 had asymptomatic DVT, and 24 had symptomatic VTE. The incidence of ACM was 4.8% in patients without VTE. Both asymptomatic proximal DVT (mortality, 11.4%; hazard ratio [HR], 2.31; 95% CI, 1.52-3.51; P<0.0001) and symptomatic VTE (mortality, 29.2%; HR, 9.42; 95% CI, 4.18-21.20; P<0.0001) were independently associated with significant increases in ACM. The analysis was post hoc, and ultrasound results were not available for all patients. Adjustment for baseline variables significantly associated with ACM may not fully compensate for differences. Conclusions Asymptomatic proximal DVT is associated with higher ACM than no VTE and remains a relevant end point to evaluate the efficacy of anticoagulant thromboprophylaxis in medical patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00571649.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City OK
| | - Alex C Spyropoulos
- The Feinstein Institutes for Medical Research and Zucker School of Medicine at Hofstra/Northwell Anticoagulation and Clinical Thrombosis Services Department of Medicine Northwell Health at Lenox Hill Hospital New York NY
| | - Alexander T Cohen
- Department of Hematological Medicine Guys and St Thomas/NHS Foundation Trust, King's College London London United Kingdom
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | | | - Wentao Lu
- Biostatistics Department Janssen Research and Development LLC Raritan NJ
| | - Jianfeng Xu
- Biostatistics Department Janssen Research and Development LLC Raritan NJ
| | - John Albanese
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Chiara Sugarmann
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Traci Weber
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Concetta Lipardi
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | | | - Elliot S Barnathan
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
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15
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Lo KH, Donohue J, Judson MA, Wu Y, Barnathan ES, Baughman RP. The St. George's Respiratory Questionnaire in Pulmonary Sarcoidosis. Lung 2020; 198:917-924. [PMID: 32979072 DOI: 10.1007/s00408-020-00394-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/19/2020] [Indexed: 01/17/2023]
Abstract
RATIONALE The Saint George's Respiratory Questionnaire (SGRQ) is a frequently used tool to assess health status in pulmonary disease patients. However, its performance characteristics in sarcoidosis patients are not well characterized. METHODS Data from a clinical trial of 138 symptomatic adults with sarcoidosis were used to examine the performance characteristics of SGRQ. Data were available at both baseline and week 24. Other assessments included FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6-min walk distance (6MWD), and Short Form-36 Physical Component Summary (SF-36 PCS) score. RESULTS Baseline SGRQ was 46.8, indicating impaired health status. At baseline, SGRQ total score correlated significantly with % predicted FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6MWD, and SF-36 PCS (r = - 0.37, - 0.32, 0.57, 0.40, - 0.55, and - 0.80, respectively, p < 0.001). Change from baseline in SGRQ score also statistically significantly correlated with change from baseline in these parameters at week 24: r = - 0.25, - 0.20, 0.30, 0.22, - 0.20, - 0.45, respectively (p < 0.05). CONCLUSIONS The SGRQ correlated with other outcome measures in sarcoidosis initially and with treatment. Improvement in FVC % predicted correlated with improvement in SGRQ. These data suggest the SGRQ may function as a reliable endpoint in clinical sarcoidosis trials.
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Affiliation(s)
- K H Lo
- Janssen Research and Development, LLC, Raritan, USA
| | - J Donohue
- The University of North Carolina, Chapel Hill, NC, USA
| | | | - Y Wu
- Janssen Research and Development, LLC, Raritan, USA
| | | | - R P Baughman
- The University of Cincinnati Medical Center, 200 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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16
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Pawlowski C, Wagner T, Puranik A, Murugadoss K, Loscalzo L, Venkatakrishnan AJ, Pruthi RK, Houghton DE, O'Horo JC, Morice WG, Williams AW, Gores GJ, Halamka J, Badley AD, Barnathan ES, Makimura H, Khan N, Soundararajan V. Inference from longitudinal laboratory tests characterizes temporal evolution of COVID-19-associated coagulopathy (CAC). eLife 2020; 9:59209. [PMID: 32804081 PMCID: PMC7473767 DOI: 10.7554/elife.59209] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/14/2020] [Indexed: 01/05/2023] Open
Abstract
Temporal inference from laboratory testing results and triangulation with clinical outcomes extracted from unstructured electronic health record (EHR) provider notes is integral to advancing precision medicine. Here, we studied 246 SARS-CoV-2 PCR-positive (COVIDpos) patients and propensity-matched 2460 SARS-CoV-2 PCR-negative (COVIDneg) patients subjected to around 700,000 lab tests cumulatively across 194 assays. Compared to COVIDneg patients at the time of diagnostic testing, COVIDpos patients tended to have higher plasma fibrinogen levels and lower platelet counts. However, as the infection evolves, COVIDpos patients distinctively show declining fibrinogen, increasing platelet counts, and lower white blood cell counts. Augmented curation of EHRs suggests that only a minority of COVIDpos patients develop thromboembolism, and rarely, disseminated intravascular coagulopathy (DIC), with patients generally not displaying platelet reductions typical of consumptive coagulopathies. These temporal trends provide fine-grained resolution into COVID-19 associated coagulopathy (CAC) and set the stage for personalizing thromboprophylaxis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - William G Morice
- Mayo Clinic, Rochester, United States.,Mayo Clinic Laboratories, Rochester, United States
| | | | | | - John Halamka
- Mayo Clinic, Rochester, United States.,Mayo Clinic Platform, Rochester, United States
| | | | - Elliot S Barnathan
- Janssen pharmaceutical companies of Johnson & Johnson (J&J), Spring House, United States
| | - Hideo Makimura
- Janssen pharmaceutical companies of Johnson & Johnson (J&J), Spring House, United States
| | - Najat Khan
- Janssen pharmaceutical companies of Johnson & Johnson (J&J), Spring House, United States
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17
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Affiliation(s)
- Alex C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Center for Health Innovation and Outcomes Research, Feinstein Institutes for Medical Research, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York City, 10577 NY, USA.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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18
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Spyropoulos AC, Lipardi C, Xu J, Lu W, Suh E, Yuan Z, Levitan B, Sugarmann C, De Sanctis Y, Spiro TE, Barnathan ES, Raskob GE. Improved Benefit Risk Profile of Rivaroxaban in a Subpopulation of the MAGELLAN Study. Clin Appl Thromb Hemost 2020; 25:1076029619886022. [PMID: 31746218 PMCID: PMC7019408 DOI: 10.1177/1076029619886022] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Acutely ill medical patients are at risk of venous thromboembolism (VTE) and VTE-related
mortality during hospitalization and posthospital discharge, but widespread adoption of
extended thromboprophylaxis has not occurred. We analyzed a subpopulation within the
MAGELLAN study of extended thromboprophylaxis with rivaroxaban to reevaluate the benefit
risk profile. We identified 5 risk factors for major and fatal bleeding after a clinical
analysis of the MAGELLAN study and analyzed efficacy and safety with these patients
excluded (n = 1551). Risk factors included: active cancer, dual antiplatelet therapy at
baseline, bronchiectasis/pulmonary cavitation, gastroduodenal ulcer, or bleeding within 3
months before randomization. We evaluated efficacy, safety, and benefit risk using
clinically comparable endpoints in the subpopulation. At day 10, rivaroxaban was
noninferior to enoxaparin (relative risk [RR] = 0.82, 95% confidence interval [CI] =
0.58-1.15) and at day 35 rivaroxaban was significantly better than enoxaparin/placebo (RR
= 0.68, 95% CI = 0.53-0.88) in reducing VTE and VTE-related death. Major bleeding was
reduced at day 10 (RR = 2.18, 95% CI = 1.07-4.44 vs 1.19, 95% CI = 0.54-2.65) and at day
35 (2.87, 95% CI = 1.60-5.15 vs 1.48, 95% CI = 0.77-2.84) for MAGELLAN versus this
subpopulation, respectively. The benefit risk profile was favorable in this subpopulation
treated for 35 days, with the number needed to treat ranging from 55 to 481 and number
needed to harm from 455 to 1067 for all pairwise evaluations. Five exclusionary criteria
defined a subpopulation of acutely ill medical patients with a positive benefit risk
profile for in-hospital and extended thromboprophylaxis with rivaroxaban.
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Affiliation(s)
- Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, NY, USA
| | | | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Eunyoung Suh
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Yoriko De Sanctis
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | - Theodore E Spiro
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | | | - Gary E Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Dhondalay GKR, Bunning B, Bauer RN, Barnathan ES, Maniscalco C, Baribaud F, Nadeau KC, Andorf S. Transcriptomic and methylomic features in asthmatic and nonasthmatic twins. Allergy 2020; 75:989-992. [PMID: 31758558 DOI: 10.1111/all.14128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gopal Krishna R. Dhondalay
- Sean N. Parker Center for Allergy and Asthma Research Stanford University School of Medicine Stanford CA USA
| | - Bryan Bunning
- Sean N. Parker Center for Allergy and Asthma Research Stanford University School of Medicine Stanford CA USA
| | | | | | | | | | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research Stanford University School of Medicine Stanford CA USA
| | - Sandra Andorf
- Sean N. Parker Center for Allergy and Asthma Research Stanford University School of Medicine Stanford CA USA
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Weitz JI, Raskob GE, Spyropoulos AC, Spiro TE, De Sanctis Y, Xu J, Lu W, Suh E, Argenti D, Yang H, Albanese J, Lipardi C, Barnathan ES. Thromboprophylaxis with Rivaroxaban in Acutely Ill Medical Patients with Renal Impairment: Insights from the MAGELLAN and MARINER Trials. Thromb Haemost 2020; 120:515-524. [DOI: 10.1055/s-0039-1701009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AbstractPatients with renal impairment are at higher risk of thrombosis and bleeding than those with normal renal function. The optimal rivaroxaban dose for thromboprophylaxis in acutely ill medical patients with renal impairment is unknown. MARINER and MAGELLAN were multicenter, randomized clinical trials of rivaroxaban in acutely ill medical patients. Efficacy and safety outcomes in patients with renal impairment in MARINER (7.5 mg once daily) were compared with those in patients with normal renal function in MARINER (10 mg once daily) and in a subpopulation of MAGELLAN that excluded patients at high risk for bleeding at baseline (10 mg once daily). Compared with enoxaparin/placebo in the MAGELLAN subpopulation, the relative risk (RR) of symptomatic venous thromboembolism (VTE) and VTE-related death with rivaroxaban 10 mg in patients with renal impairment (RR = 0.62; 95% confidence interval [CI] 0.27–1.44) was similar to that in those with normal renal function (RR = 0.78; 95% CI 0.44–1.40), while in MARINER, the 7.5 mg dose did not reduce the risk in patients with renal impairment (hazard ratio = 1.00; 95% CI 0.52–1.92). Major bleeding with rivaroxaban 10 mg once daily was higher in patients with renal impairment than in those with normal renal function in MAGELLAN (1.54% vs. 0.98%) and in the MAGELLAN subpopulation (0.94% vs. 0.61%). At a dose of 10 mg once daily, rivaroxaban is effective for thromboprophylaxis in acutely ill medical patients with impaired or normal renal function. The safety of this regimen is enhanced without loss of efficacy by excluding patients at high risk for bleeding, but not by using a reduced-dose strategy.
Trial Registration ClinicalTrials.gov identifiers: NCT00571649 for the MAGELLAN trial, NCT02111564 for the MARINER trial.
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Affiliation(s)
- Jeffrey I. Weitz
- The Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Gary E. Raskob
- College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - Alex C. Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, United States
- The Feinstein Institute for Medical Research, New York, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
| | - Theodore E. Spiro
- Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, New Jersey, United States
| | - Yoriko De Sanctis
- Statistics and Data Insights, Bayer U.S. LLC, Whippany, New Jersey, United States
| | - Jianfeng Xu
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - Wentao Lu
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - Eunyoung Suh
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - Domenick Argenti
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - Haitao Yang
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - John Albanese
- Janssen Research and Development LLC, Raritan, New Jersey, United States
| | - Concetta Lipardi
- Janssen Research and Development LLC, Raritan, New Jersey, United States
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Spyropoulos AC, Lipardi C, Xu J, Peluso C, Spiro TE, De Sanctis Y, Barnathan ES, Raskob GE. Modified IMPROVE VTE Risk Score and Elevated D-Dimer Identify a High Venous Thromboembolism Risk in Acutely Ill Medical Population for Extended Thromboprophylaxis. TH Open 2020; 4:e59-e65. [PMID: 32190813 PMCID: PMC7069762 DOI: 10.1055/s-0040-1705137] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/27/2020] [Indexed: 12/19/2022] Open
Abstract
An individualized approach to identify acutely ill medical patients at increased risk of venous thromboembolism (VTE) and a low risk of bleeding to optimize the benefit and risk of extended thromboprophylaxis (ET) is needed. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk score has undergone extensive external validation in medically ill patients for in-hospital use and a modified model was used in the MARINER trial of ET also incorporating an elevated D-dimer. The MAGELLAN study demonstrated efficacy with rivaroxaban but had excess bleeding. This retrospective analysis investigated whether the modified IMPROVE VTE model with an elevated D-dimer could identify a high VTE risk subgroup of patients for ET from a subpopulation of the MAGELLAN study, which was previously identified as having a lower risk of bleeding. We incorporated the modified IMPROVE VTE score using a cutoff score of 4 or more or 2 and 3 with an elevated D-dimer (>2 times the upper limit of normal) to the MAGELLAN subpopulation. In total, 56% of the patients met the high-risk criteria. In the placebo group, the total VTE event rate at Day 35 was 7.94% in the high-risk group and 2.83% for patients in the lower-risk group. A reduction in VTE was observed with rivaroxaban in the high-risk group (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.51-0.91, p = 0.008) and in the lower-risk group (RR: 0.69, 95% CI: 0.40 -1.20, p = 0.187). The modified IMPROVE VTE score with an elevated D-dimer identified a nearly threefold higher VTE risk subpopulation of patients where a significant benefit exists for ET using rivaroxaban.
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Affiliation(s)
- Alex C. Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, New York, New York, United States
| | - Concetta Lipardi
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Colleen Peluso
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Theodore E. Spiro
- Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, New Jersey, United States
| | - Yoriko De Sanctis
- Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, New Jersey, United States
| | | | - Gary E. Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
- Address for correspondence Alex C. Spyropoulos, MD The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital130 E 77th St, New York, NY 10075United States
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22
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Zhu J, Message SD, Mallia P, Kebadze T, Contoli M, Ward CK, Barnathan ES, Mascelli MA, Kon OM, Papi A, Stanciu LA, Edwards MR, Jeffery PK, Johnston SL. Bronchial mucosal IFN-α/β and pattern recognition receptor expression in patients with experimental rhinovirus-induced asthma exacerbations. J Allergy Clin Immunol 2019; 143:114-125.e4. [PMID: 29698627 PMCID: PMC6320262 DOI: 10.1016/j.jaci.2018.04.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The innate immune system senses viral infection through pattern recognition receptors (PRRs), leading to type I interferon production. The role of type I interferon and PPRs in rhinovirus-induced asthma exacerbations in vivo are uncertain. OBJECTIVES We sought to compare bronchial mucosal type I interferon and PRR expression at baseline and after rhinovirus infection in atopic asthmatic patients and control subjects. METHODS Immunohistochemistry was used to detect expression of IFN-α, IFN-β, and the PRRs: Toll-like receptor 3, melanoma differentiation-associated gene 5, and retinoic acid-inducible protein I in bronchial biopsy specimens from 10 atopic asthmatic patients and 15 nonasthmatic nonatopic control subjects at baseline and on day 4 and 6 weeks after rhinovirus infection. RESULTS We observed IFN-α/β deficiency in the bronchial epithelium at 3 time points in asthmatic patients in vivo. Lower epithelial IFN-α/β expression was related to greater viral load, worse airway symptoms, airway hyperresponsiveness, and reductions in lung function during rhinovirus infection. We found lower frequencies of bronchial subepithelial monocytes/macrophages expressing IFN-α/β in asthmatic patients during infection. Interferon deficiency at baseline was not accompanied by deficient PRR expression in asthmatic patients. Both epithelial and subepithelial PRR expression were induced during rhinovirus infection. Rhinovirus infection-increased numbers of subepithelial interferon/PRR-expressing inflammatory cells were related to greater viral load, airway hyperresponsiveness, and reductions in lung function. CONCLUSIONS Bronchial epithelial IFN-α/β expression and numbers of subepithelial IFN-α/β-expressing monocytes/macrophages during infection were both deficient in asthmatic patients. Lower epithelial IFN-α/β expression was associated with adverse clinical outcomes after rhinovirus infection in vivo. Increases in numbers of subepithelial cells expressing interferon/PRRs during infection were also related to greater viral load/illness severity.
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Affiliation(s)
- Jie Zhu
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Simon D Message
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Patrick Mallia
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tatiana Kebadze
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Marco Contoli
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom; Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | | | | | | | - Onn M Kon
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - Luminita A Stanciu
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Michael R Edwards
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Peter K Jeffery
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Sebastian L Johnston
- Airway Disease Infection, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom.
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Affiliation(s)
- Alex C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | | | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
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24
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Spyropoulos AC, Ageno W, Albers GW, Elliott CG, Halperin JL, Hiatt WR, Maynard GA, Steg PG, Weitz JI, Suh E, Spiro TE, Barnathan ES, Raskob GE. Rivaroxaban for Thromboprophylaxis after Hospitalization for Medical Illness. N Engl J Med 2018; 379:1118-1127. [PMID: 30145946 DOI: 10.1056/nejmoa1805090] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients who are hospitalized for medical illness remain at risk for venous thromboembolism after discharge, but the role of extended thromboprophylaxis in the treatment of such patients is a subject of controversy. METHODS In this randomized, double-blind trial, medically ill patients who were at increased risk for venous thromboembolism on the basis of a modified International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score of 4 or higher (scores range from 0 to 10, with higher scores indicating a higher risk of venous thromboembolism) or a score of 2 or 3 plus a plasma d-dimer level of more than twice the upper limit of the normal range (defined according to local laboratory criteria) were assigned at hospital discharge to either once-daily rivaroxaban at a dose of 10 mg (with the dose adjusted for renal insufficiency) or placebo for 45 days. The primary efficacy outcome was a composite of symptomatic venous thromboembolism or death due to venous thromboembolism. The principal safety outcome was major bleeding. RESULTS Of the 12,024 patients who underwent randomization, 12,019 were included in the intention-to-treat analysis. The primary efficacy outcome occurred in 50 of 6007 patients (0.83%) who were given rivaroxaban and in 66 of 6012 patients (1.10%) who were given placebo (hazard ratio, 0.76; 95% confidence interval [CI], 0.52 to 1.09; P=0.14). The prespecified secondary outcome of symptomatic nonfatal venous thromboembolism occurred in 0.18% of patients in the rivaroxaban group and 0.42% of patients in the placebo group (hazard ratio, 0.44; 95% CI, 0.22 to 0.89). Major bleeding occurred in 17 of 5982 patients (0.28%) in the rivaroxaban group and in 9 of 5980 patients (0.15%) in the placebo group (hazard ratio, 1.88; 95% CI, 0.84 to 4.23). CONCLUSIONS Rivaroxaban, given to medical patients for 45 days after hospital discharge, was not associated with a significantly lower risk of symptomatic venous thromboembolism and death due to venous thromboembolism than placebo. The incidence of major bleeding was low. (Funded by Janssen Research and Development; MARINER ClinicalTrials.gov number, NCT02111564 .).
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Affiliation(s)
- Alex C Spyropoulos
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Walter Ageno
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Gregory W Albers
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - C Gregory Elliott
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Jonathan L Halperin
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - William R Hiatt
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Gregory A Maynard
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - P Gabriel Steg
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Jeffrey I Weitz
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Eunyoung Suh
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Theodore E Spiro
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Elliot S Barnathan
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Gary E Raskob
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, and the Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital (A.C.S.), and the Cardiovascular Institute, Mount Sinai Medical Center (J.L.H.) - all in New York; the Department of Medicine and Surgery, University of Insubria, Varese, Italy (W.A.); the Stanford Stroke Center, Stanford University Medical Center, Stanford (G.W.A.), and the University of California at Davis, Sacramento (G.A.M.) - both in California; the Department of Medicine, Intermountain Medical Center, and Department of Medicine, University of Utah, Salt Lake City (C.G.E.); Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora (W.R.H.); Département Hospitalo-Universitaire FIRE (Fibrose Inflammation Remodelage), University Paris Diderot, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); Imperial College, Royal Brompton Hospital, London (P.G.S.); McMaster University and the Thrombosis and Atherosclerosis Research Institute - both in Hamilton, ON, Canada (J.I.W.); Janssen Research and Development, Raritan (E.S., E.S.B.), and the Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S., Whippany (T.E.S.) - both in New Jersey; and the College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
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25
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Kollmeier AP, Barnathan ES, O'Brien C, Chen B, Xia YK, Zhou B, Loza MJ, Silkoff PE, Ge M, Thurmond RL. A phase 2a study of toreforant, a histamine H 4 receptor antagonist, in eosinophilic asthma. Ann Allergy Asthma Immunol 2018; 121:568-574. [PMID: 30102965 DOI: 10.1016/j.anai.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/25/2018] [Accepted: 08/06/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Data from preclinical and clinical studies support the evaluation of histamine 4 receptor antagonists in the treatment of asthma. Toreforant is a selective histamine 4 receptor antagonist that could be effective in patients with eosinophilic asthma. OBJECTIVE To evaluate the efficacy and safety of toreforant in patients with eosinophilic, persistent asthma that was inadequately controlled despite current treatment. METHODS In this phase 2a, multicenter, randomized, double-blinded, parallel-group, placebo-controlled, proof-of-concept study, 162 eligible patients were randomized (1:1) to placebo or 30 mg of toreforant once daily through week 24 and followed for 4 weeks. The primary end point was change from baseline in pre-bronchodilator percent-predicted forced expiratory volume in 1 second at week 16. Secondary end points included change from baseline at week 16 in postbronchodilator percent-predicted forced expiratory volume in 1 second, Asthma Control Questionnaire scores, weekly averages of Daytime and Nighttime Asthma Diary Symptom Scores, and weekly average of number of puffs in a day that rescue medication was used. RESULTS There was no significant difference between groups in pre-bronchodilator percent-predicted forced expiratory volume in 1 second at week 16 (difference in least-square means -0.19%; 95% confidence interval -3.01 to 2.64; P = .90). Similarly, there were no significant differences between groups at week 16 in changes from baseline in the secondary end points (P ≥ .30). Toreforant was generally well tolerated. No deaths or serious adverse events were reported at any time point. CONCLUSION Toreforant, at the dose tested, failed to provide therapeutic benefit in this population of patients with uncontrolled, eosinophilic, persistent asthma. TRIAL REGISTRATION ClinicalTrials.gov, NCT01823016.
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Affiliation(s)
| | | | | | | | | | - Bei Zhou
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - Matthew J Loza
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | | | - Michelle Ge
- Genocea Biosciences, Inc, Cambridge, Massachusetts
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26
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Hollas W, Hoosein N, Chung LWK, Mazar A, Henkin J, Kariko K, Barnathan ES, Boyd D. Expression of Urokinase and Its Receptor in Invasive and Non-Invasive Prostate Cancer Cell Lines. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1646340] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryWe previously reported that extracellular matrix invasion by the prostate cancer cell lines, PC-3 and DU-145 was contingent on endogenous urokinase being bound to a specific cell surface receptor. The present study was undertaken to characterize the expression of both urokinase and its receptor in the non-invasive LNCaP and the invasive PC-3 and DU-145 prostate cells. Northern blotting indicated that the invasive PC-3 cells, which secreted 10 times more urokinase (680 ng/ml per 106 cells per 48 h) than DU-145 cells (63 ng/ml per 106 cells per 48 h), had the most abundant transcript for the plasminogen activator. This, at least, partly reflected a 3 fold amplification of the urokinase gene in the PC-3 cells. In contrast, urokinase-specific transcript could not be detected in the non-invasive LNCaP cells previously characterized as being negative for urokinase protein. Southern blotting indicated that this was not a consequence of deletion of the urokinase gene. Crosslinking of radiolabelled aminoterminal fragment of urokinase to the cell surface indicated the presence of a 51 kDa receptor in extracts of the invasive PC-3 and DU-145 cells but not in extracts of the non-invasive LNCaP cells. The amount of binding protein correlated well with binding capacities calculated by Scatchard analysis. In contrast, the steady state level of urokinase receptor transcript was a poor predictor of receptor display. PC-3 cells, which were equipped with 25,000 receptors per cell had 2.5 fold more steady state transcript than DU-145 cells which displayed 93,000 binding sites per cell.
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Affiliation(s)
- W Hollas
- The Department of Tumor Biology, M. D. Anderson Cancer Center, Houston, TX, USA
| | - N Hoosein
- The Urology Research Laboratory, M. D. Anderson Cancer Center, Houston, TX, USA
| | - L W K Chung
- The Urology Research Laboratory, M. D. Anderson Cancer Center, Houston, TX, USA
| | - A Mazar
- The Thrombolytics Venture Abbott Labs, Abbott Park, IL, USA
| | - J Henkin
- The Thrombolytics Venture Abbott Labs, Abbott Park, IL, USA
| | - K Kariko
- The Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E S Barnathan
- The Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D Boyd
- The Department of Tumor Biology, M. D. Anderson Cancer Center, Houston, TX, USA
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27
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Kollmeier AP, Greenspan A, Xu XL, Silkoff PE, Barnathan ES, Loza MJ, Jiang J, Zhou B, Chen B, Thurmond RL. Phase 2a, randomized, double-blind, placebo-controlled, multicentre, parallel-group study of an H 4 R-antagonist (JNJ-39758979) in adults with uncontrolled asthma. Clin Exp Allergy 2018; 48:957-969. [PMID: 29682796 DOI: 10.1111/cea.13154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effects of H4 R antagonists in preclinical asthma models support the study of antagonists of the H4 R in the treatment of asthma in humans. JNJ-39758979 is a potent and highly selective oral H4 R antagonist. OBJECTIVE We sought to evaluate the safety and efficacy of the H4 R-antagonist JNJ-39758979 in adult patients with uncontrolled asthma. METHODS One hundred and fifteen eligible patients were randomly assigned to JNJ-39758979 300 mg or placebo once daily for 12 weeks in this phase 2a, double-blind, multicenter, placebo-controlled study. Primary efficacy was assessed via week-12 change from baseline in pre-bronchodilator forced expiratory volume in 1 second (FEV1 ). Secondary efficacy assessments included patient-reported outcome (PRO) asthma assessments (Asthma Daily Diary data [AM and PM peak expiratory flow rate, number of puffs of albuterol/salbutamol, the presence of nocturnal awakenings and asthma symptom score]). RESULTS The study did not meet the primary end-point. However, nominally significant improvements in pre-bronchodilator FEV1 were observed with JNJ-39758979 versus placebo at week 12 in pre-specified subgroups with elevated exhaled nitric oxide, sputum eosinophils or blood eosinophils at baseline. Nominally significant improvements across PRO assessments were consistently observed in the overall population, as well as in eosinophilic subgroups. Safety, such as adverse event rates, was comparable between JNJ-39758979 and placebo. No serious adverse events were reported. No clinically relevant changes in laboratory values were observed. CONCLUSIONS AND CLINICAL RELEVANCE The findings suggest potential benefit of H4 R antagonists on lung function and asthma control in eosinophilic asthma patients and warrant further evaluation of this mechanism in asthma with eosinophilic inflammation. NCT00946569.
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Affiliation(s)
- A P Kollmeier
- Janssen Research & Development, LLC, San Diego, CA, USA
| | - A Greenspan
- Janssen Research & Development, LLC, San Diego, CA, USA
| | - X L Xu
- Janssen Research & Development, LLC, San Diego, CA, USA
| | - P E Silkoff
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - E S Barnathan
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - M J Loza
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - J Jiang
- Janssen Research & Development, LLC, San Diego, CA, USA
| | - B Zhou
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - B Chen
- Janssen Research & Development, LLC, San Diego, CA, USA
| | - R L Thurmond
- Janssen Research & Development, LLC, San Diego, CA, USA
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28
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Silkoff PE, Flavin S, Gordon R, Loza MJ, Sterk PJ, Lutter R, Diamant Z, Turner RB, Lipworth BJ, Proud D, Singh D, Eich A, Backer V, Gern JE, Herzmann C, Halperin SA, Mensinga TT, Del Vecchio AM, Branigan P, San Mateo L, Baribaud F, Barnathan ES, Johnston SL. Toll-like receptor 3 blockade in rhinovirus-induced experimental asthma exacerbations: A randomized controlled study. J Allergy Clin Immunol 2017; 141:1220-1230. [PMID: 28734844 DOI: 10.1016/j.jaci.2017.06.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 06/04/2017] [Accepted: 06/12/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Human rhinoviruses (HRVs) commonly precipitate asthma exacerbations. Toll-like receptor 3, an innate pattern recognition receptor, is triggered by HRV, driving inflammation that can worsen asthma. OBJECTIVE We sought to evaluate an inhibitory mAb to Toll-like receptor 3, CNTO3157, on experimental HRV-16 inoculation in healthy subjects and asthmatic patients. METHODS In this double-blind, multicenter, randomized, parallel-group study in North America and Europe, healthy subjects and patients with mild-to-moderate stable asthma received single or multiple doses of CNTO3157 or placebo, respectively, and were then inoculated with HRV-16 within 72 hours. All subjects were monitored for respiratory symptoms, lung function, and nasal viral load. The primary end point was maximal decrease in FEV1 during 10 days after inoculation. RESULTS In asthmatic patients (n = 63) CNTO3157 provided no protection against FEV1 decrease (least squares mean: CNTO3157 [n = 30] = -7.08% [SE, 8.15%]; placebo [n = 25] = -5.98% [SE, 8.56%]) or symptoms after inoculation. In healthy subjects (n = 12) CNTO3157 versus placebo significantly attenuated upper (P = .03) and lower (P = .02) airway symptom scores, with area-under-the-curve increases of 9.1 (15.1) versus 34.9 (17.6) and 13.0 (18.4) versus 50.4 (25.9) for the CNTO3157 (n = 8) and placebo (n = 4) groups, respectively, after inoculation. All of the severe and 4 of the nonserious asthma exacerbations occurred while receiving CNTO3157. CONCLUSION In summary, CNTO3157 was ineffective in attenuating the effect of HRV-16 challenge on lung function, asthma control, and symptoms in asthmatic patients but suppressed cold symptoms in healthy subjects. Other approaches, including blockade of multiple pathways or antiviral agents, need to be sought for this high unmet medical need.
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Affiliation(s)
| | - Susan Flavin
- Janssen Research & Development LLC, Spring House, Pa
| | - Robert Gordon
- Janssen Research & Development LLC, Spring House, Pa
| | - Mathew J Loza
- Janssen Research & Development LLC, Spring House, Pa
| | - Peter J Sterk
- Department of Respiratory Medicine F5-259, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Rene Lutter
- Departments of Respiratory Medicine and Experimental Immunology, K0-150, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Zuzana Diamant
- Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund, and QPS Netherlands, Groningen, The Netherlands
| | - Ronald B Turner
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - David Proud
- Department of Physiology & Pharmacology, Snyder Institute for Chronic Diseases, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Andreas Eich
- IKF Pneumologie Frankfurt, Clinical Research Center Respiratory Diseases, Frankfurt, Germany
| | - Vibeke Backer
- Department of Respiratory Medicine, Copenhagen, Denmark
| | - James E Gern
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wis
| | | | - Scott A Halperin
- Canadian Center for Vaccinology, Dalhousie University and the IWK Health Centre, Halifax, Canada
| | | | | | | | | | | | | | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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29
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Monast CS, Li K, Judson MA, Baughman RP, Wadman E, Watt R, Silkoff PE, Barnathan ES, Brodmerkel C. Sarcoidosis extent relates to molecular variability. Clin Exp Immunol 2017; 188:444-454. [PMID: 28205212 DOI: 10.1111/cei.12942] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 12/22/2022] Open
Abstract
The molecular basis of sarcoidosis phenotype heterogeneity and its relationship to effective treatment of sarcoidosis have not been elucidated. Peripheral samples from sarcoidosis subjects who participated in a Phase II study of golimumab [anti-tumour necrosis factor (TNF)-α] and ustekinumab [anti-interleukin (IL)-12p40] were used to measure the whole blood transcriptome and levels of serum proteins. Differential gene and protein expression analyses were used to explore the molecular differences between sarcoidosis phenotypes as defined by extent of organ involvement. The same data were also used in conjunction with an enrichment algorithm to identify gene expression changes associated with treatment with study drugs compared to placebo. Our analyses revealed marked heterogeneity among the three sarcoidosis phenotypes included in the study cohort, including striking differences in enrichment of the interferon pathway. Conversely, enrichments of multiple pathways, including T cell receptor signalling, were similar among phenotypes. We also identify differences between treatment with golimumab and ustekinumab that may explain the differences in trends for clinical efficacy observed in the trial. We find that molecular heterogeneity is associated with sarcoidosis in a manner that may be related to the extent of organ involvement. These findings may help to explain the difficulty in identifying clinically efficacious sarcoidosis treatments and suggest hypotheses for improved therapeutic strategies.
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Affiliation(s)
- C S Monast
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - K Li
- Albany Medical College, Albany, NY, USA
| | | | - R P Baughman
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - E Wadman
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - R Watt
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - P E Silkoff
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - E S Barnathan
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - C Brodmerkel
- Janssen Research & Development, LLC, Spring House, PA, USA
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30
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Silkoff PE, Laviolette M, Singh D, FitzGerald JM, Kelsen S, Backer V, Porsbjerg CM, Girodet PO, Berger P, Kline JN, Chupp G, Susulic VS, Barnathan ES, Baribaud F, Loza MJ, Lam S, Eich A, Ludwig-Sengpiel A, Leigh R, Dransfield M, Calhoun W, Hussaini A, Chanez P. Identification of airway mucosal type 2 inflammation by using clinical biomarkers in asthmatic patients. J Allergy Clin Immunol 2017; 140:710-719. [PMID: 28089872 DOI: 10.1016/j.jaci.2016.11.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 11/06/2016] [Accepted: 11/21/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Airways Disease Endotyping for Personalized Therapeutics (ADEPT) study profiled patients with mild, moderate, and severe asthma and nonatopic healthy control subjects. OBJECTIVE We explored this data set to define type 2 inflammation based on airway mucosal IL-13-driven gene expression and how this related to clinically accessible biomarkers. METHODS IL-13-driven gene expression was evaluated in several human cell lines. We then defined type 2 status in 25 healthy subjects, 28 patients with mild asthma, 29 patients with moderate asthma, and 26 patients with severe asthma based on airway mucosal expression of (1) CCL26 (the most differentially expressed gene), (2) periostin, or (3) a multigene IL-13 in vitro signature (IVS). Clinically accessible biomarkers included fraction of exhaled nitric oxide (Feno) values, blood eosinophil (bEOS) counts, serum CCL26 expression, and serum CCL17 expression. RESULTS Expression of airway mucosal CCL26, periostin, and IL-13-IVS all facilitated segregation of subjects into type 2-high and type 2-low asthmatic groups, but in the ADEPT study population CCL26 expression was optimal. All subjects with high airway mucosal CCL26 expression and moderate-to-severe asthma had Feno values (≥35 ppb) and/or high bEOS counts (≥300 cells/mm3) compared with a minority (36%) of subjects with low airway mucosal CCL26 expression. A combination of Feno values, bEOS counts, and serum CCL17 and CCL26 expression had 100% positive predictive value and 87% negative predictive value for airway mucosal CCL26-high status. Clinical variables did not differ between subjects with type 2-high and type 2-low status. Eosinophilic inflammation was associated with but not limited to airway mucosal type 2 gene expression. CONCLUSION A panel of clinical biomarkers accurately classified type 2 status based on airway mucosal CCL26, periostin, or IL-13-IVS gene expression. Use of Feno values, bEOS counts, and serum marker levels (eg, CCL26 and CCL17) in combination might allow patient selection for novel type 2 therapeutics.
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Affiliation(s)
| | - Michel Laviolette
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), Quebec City, Quebec, Canada
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, University of Manchester, and the Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Lung Centre, Gordon and Leslie Diamond Health Care Centre, Vancouver, British Columbia, Canada
| | - Steven Kelsen
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, Pa
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Celeste M Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Pierre-Olivier Girodet
- Université Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Patrick Berger
- Université Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Joel N Kline
- Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, Iowa
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31
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Loza MJ, Djukanovic R, Chung KF, Horowitz D, Ma K, Branigan P, Barnathan ES, Susulic VS, Silkoff PE, Sterk PJ, Baribaud F. Validated and longitudinally stable asthma phenotypes based on cluster analysis of the ADEPT study. Respir Res 2016; 17:165. [PMID: 27978840 PMCID: PMC5159977 DOI: 10.1186/s12931-016-0482-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 12/01/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Asthma is a disease of varying severity and differing disease mechanisms. To date, studies aimed at stratifying asthma into clinically useful phenotypes have produced a number of phenotypes that have yet to be assessed for stability and to be validated in independent cohorts. The aim of this study was to define and validate, for the first time ever, clinically driven asthma phenotypes using two independent, severe asthma cohorts: ADEPT and U-BIOPRED. METHODS Fuzzy partition-around-medoid clustering was performed on pre-specified data from the ADEPT participants (n = 156) and independently on data from a subset of U-BIOPRED asthma participants (n = 82) for whom the same variables were available. Models for cluster classification probabilities were derived and applied to the 12-month longitudinal ADEPT data and to a larger subset of the U-BIOPRED asthma dataset (n = 397). High and low type-2 inflammation phenotypes were defined as high or low Th2 activity, indicated by endobronchial biopsies gene expression changes downstream of IL-4 or IL-13. RESULTS Four phenotypes were identified in the ADEPT (training) cohort, with distinct clinical and biomarker profiles. Phenotype 1 was "mild, good lung function, early onset", with a low-inflammatory, predominantly Type-2, phenotype. Phenotype 2 had a "moderate, hyper-responsive, eosinophilic" phenotype, with moderate asthma control, mild airflow obstruction and predominant Type-2 inflammation. Phenotype 3 had a "mixed severity, predominantly fixed obstructive, non-eosinophilic and neutrophilic" phenotype, with moderate asthma control and low Type-2 inflammation. Phenotype 4 had a "severe uncontrolled, severe reversible obstruction, mixed granulocytic" phenotype, with moderate Type-2 inflammation. These phenotypes had good longitudinal stability in the ADEPT cohort. They were reproduced and demonstrated high classification probability in two subsets of the U-BIOPRED asthma cohort. CONCLUSIONS Focusing on the biology of the four clinical independently-validated easy-to-assess ADEPT asthma phenotypes will help understanding the unmet need and will aid in developing tailored therapies. TRIAL REGISTRATION NCT01274507 (ADEPT), registered October 28, 2010 and NCT01982162 (U-BIOPRED), registered October 30, 2013.
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Affiliation(s)
- Matthew J Loza
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Ratko Djukanovic
- NIHR Respiratory Biomedical Research Unit, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College & Biomedical Research Unit, Royal Brompton & Harefield NHS Trust, London, UK
| | - Daniel Horowitz
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Keying Ma
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Patrick Branigan
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Elliot S Barnathan
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Vedrana S Susulic
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Philip E Silkoff
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA
| | - Peter J Sterk
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Frédéric Baribaud
- Immunology Therapeutic Area, Janssen Research & Development LLC, 1400 McKean Rd, Spring House, 19477, USA.
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Silkoff PE, Laviolette M, Singh D, FitzGerald JM, Kelsen S, Backer V, Porsbjerg C, Girodet PO, Berger P, Kline JN, Khatri S, Chanez P, Susulic VS, Barnathan ES, Baribaud F, Loza MJ. Longitudinal stability of asthma characteristics and biomarkers from the Airways Disease Endotyping for Personalized Therapeutics (ADEPT) study. Respir Res 2016; 17:43. [PMID: 27107814 PMCID: PMC4842260 DOI: 10.1186/s12931-016-0360-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/15/2016] [Indexed: 12/15/2022] Open
Abstract
Background Asthma is a biologically heterogeneous disease and development of novel therapeutics requires understanding of pathophysiologic phenotypes. There is uncertainty regarding the stability of clinical characteristics and biomarkers in asthma over time. This report presents the longitudinal stability over 12 months of clinical characteristics and clinically accessible biomarkers from ADEPT. Methods Mild, moderate, and severe asthma subjects were assessed at 5 visits over 12 months. Assessments included patient questionnaires, spirometry, bronchodilator reversibility, fractional exhaled nitric oxide (FENO), and biomarkers measured in induced sputum. Results Mild (n = 52), moderate (n = 55), and severe (n = 51) asthma cohorts were enrolled from North America and Western Europe. For all clinical characteristics and biomarkers, group mean data showed no significant change from visit to visit. However, individual data showed considerable variability. FEV1/FVC ratio showed excellent reproducibility while pre-bronchodilator FEV1 and FVC were only moderately reproducible. Of note bronchodilator FEV1 reversibility showed low reproducibility, with the nonreversible phenotype much more reproducible than the reversible phenotype. The 7-item asthma control questionnaire (ACQ7) demonstrated moderate reproducibility for the combined asthma cohorts, but the uncontrolled asthma phenotype (ACQ7 > 1.5) was inconstant in mild and moderate asthma but stable in severe asthma. FENO demonstrated good reproducibility, with the FENO-low phenotype (FENO < 35 ppb) more stable than the FENO-high phenotype (FENO ≥ 35 ppb). Induced sputum inflammatory phenotypes showed marked variability across the 3 sputum samples taken over 6 months. Conclusions The ADEPT cohort showed group stability, individual stability in some parameters e.g. low FEV1/FVC ratio, and low FENO, but marked individual variability in other clinical characteristics and biomarkers e.g. type-2 biomarkers over 12 months. This variability is possibly related to seasonal variations in climate and allergen exposure, medication changes and acute exacerbations. The implications for patient selection strategies based on clinical biomarkers may be considerable.
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Affiliation(s)
- P E Silkoff
- Janssen Research & Development LLC, Spring House, PA, USA. .,, Present Address: 715 Bryn Mawr Avenue, Penn Valley, PA, 19072, USA.
| | - M Laviolette
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), 2725, Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
| | - D Singh
- Centre for Respiratory Medicine and Allergy, the University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK
| | - J M FitzGerald
- Institute for Heart and Lung Health, The Lung Centre, Gordon and Leslie Diamond Health Care Centre, 7th Floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - S Kelsen
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, 401N. Broad St., Philadelphia, PA, 19140, USA
| | - V Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Bispebjerg bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - C Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Bispebjerg bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - P O Girodet
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, U1045, CIC 1401, F-33000, Bordeaux, France
| | - P Berger
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, U1045, CIC 1401, F-33000, Bordeaux, France
| | - J N Kline
- Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, W219B GH UIHC, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - S Khatri
- Department of Pulmonary and Critical Care, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - P Chanez
- Pneumologie, Aix Marseille University, APHM/INSERM U1067, Chemin des Bourellys 13015, Marseille, France
| | - V S Susulic
- Janssen Research & Development LLC, Spring House, PA, USA
| | - E S Barnathan
- Janssen Research & Development LLC, Spring House, PA, USA
| | - F Baribaud
- Janssen Research & Development LLC, Spring House, PA, USA
| | - M J Loza
- Janssen Research & Development LLC, Spring House, PA, USA
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Baughman RP, Judson MA, Lower EE, Drent M, Costabel U, Flavin S, Lo KH, Barnathan ES. Infliximab for chronic cutaneous sarcoidosis: a subset analysis from a double-blind randomized clinical trial. Sarcoidosis Vasc Diffuse Lung Dis 2016; 32:289-295. [PMID: 26847095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 08/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Limited evidence exists demonstrating an effective treatment for chronic cutaneous sarcoidosis. OBJECTIVE To determine infliximab's effectiveness in sarcoidosis. METHODS We conducted a subset analysis from a randomized, double-blind, placebo-controlled trial for chronic pulmonary sarcoidosis to determine infliximab's effectiveness. Patients with chronic cutaneous sarcoidosis received infliximab (3 or 5 mg/kg) or placebo over 24 weeks. Of 138 patients, the subset analysis evaluated 17 patients with chronic facial and another 9 patients with nonfacial skin involvement. The SASI evaluated lesions for degree of erythema, desquamation, induration, and percentage of area involved. Facial and nonfacial lesions were scored in a blinded manner. RESULTS Among 5 placebo-treated and 12 infliximab-treated patients, an improvement was observed with infliximab versus placebo in change from baseline to weeks 12 and 24 in desquamation (P<0.005) and induration (P<0.01) at week 24. Erythema, percentage of area involved and the evaluation of paired photographs did not reveal significant differences. LIMITATIONS Sample size; more extensive disease in placebo patients; chronic therapy upon enrollment; lung as primary organ of sarcoidosis involvement; limited investigator experience with SASI. CONCLUSIONS Infliximab appears to be a beneficial treatment for chronic cutaneous sarcoidosis. The SASI scoring system demonstrated significant improvement versus placebo in lesion desquamation and induration.
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Affiliation(s)
- Robert P Baughman
- University of Cincinnati Medical Center, Cincinnati, OH, United States.
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Silkoff PE, Strambu I, Laviolette M, Singh D, FitzGerald JM, Lam S, Kelsen S, Eich A, Ludwig-Sengpiel A, Hupp GC, Backer V, Porsbjerg C, Girodet PO, Berger P, Leigh R, Kline JN, Dransfield M, Calhoun W, Hussaini A, Khatri S, Chanez P, Susulic VS, Barnathan ES, Curran M, Das AM, Brodmerkel C, Baribaud F, Loza MJ. Asthma characteristics and biomarkers from the Airways Disease Endotyping for Personalized Therapeutics (ADEPT) longitudinal profiling study. Respir Res 2015; 16:142. [PMID: 26576744 PMCID: PMC4650115 DOI: 10.1186/s12931-015-0299-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/31/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Asthma is a heterogeneous disease and development of novel therapeutics requires an understanding of pathophysiologic phenotypes. The purpose of the ADEPT study was to correlate clinical features and biomarkers with molecular characteristics, by profiling asthma (NCT01274507). This report presents for the first time the study design, and characteristics of the recruited subjects. METHODS Patients with a range of asthma severity and healthy non-atopic controls were enrolled. The asthmatic subjects were followed for 12 months. Assessments included history, patient questionnaires, spirometry, airway hyper-responsiveness to methacholine, fractional exhaled nitric oxide (FENO), and biomarkers measured in induced sputum, blood, and bronchoscopy samples. All subjects underwent sputum induction and 30 subjects/cohort had bronchoscopy. RESULTS Mild (n = 52), moderate (n = 55), severe (n = 51) asthma cohorts and 30 healthy controls were enrolled from North America and Western Europe. Airflow obstruction, bronchodilator response and airways hyperresponsiveness increased with asthma severity, and severe asthma subjects had reduced forced vital capacity. Asthma control questionnaire-7 (ACQ7) scores worsened with asthma severity. In the asthmatics, mean values for all clinical and biomarker characteristics were stable over 12 months although individual variability was evident. FENO and blood eosinophils did not differ by asthma severity. Induced sputum eosinophils but not neutrophils were lower in mild compared to the moderate and severe asthma cohorts. CONCLUSIONS The ADEPT study successfully enrolled asthmatics across a spectrum of severity and non-atopic controls. Clinical characteristics were related to asthma severity and in general asthma characteristics e.g. lung function, were stable over 12 months. Use of the ADEPT data should prove useful in defining biological phenotypes to facilitate personalized therapeutic approaches.
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Affiliation(s)
- P E Silkoff
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA.
| | - I Strambu
- Arensia Exploratory Medicine, Sos. Viilor 90, Bucharest, 050159, Romania.
| | - M Laviolette
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), 2725, Chemin Ste-Foy, Québec, G1V 4G5, Canada.
| | - D Singh
- Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, University of Manchester, Southmoor Road, Manchester, M23 9QZ, UK.
| | - J M FitzGerald
- Institute for Heart and Lung Health, The Lung Centre, 7th Floor, Gordon, Canada. .,Leslie Diamond Health Care Centre, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - S Lam
- Institute for Heart and Lung Health, The Lung Centre, 7th Floor, Gordon, Canada.,Leslie Diamond Health Care Centre, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - S Kelsen
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, 3401 N. Broad St., Philadelphia, PA, 19140, USA.
| | - A Eich
- IKF Pneumologie Frankfurt, Institut für klinische Forschung Pneumologie, Clinical Research Centre Respiratory Diseases, Schaumainkai 101-103, Stresemannallee, 360596, Frankfurt, Germany.
| | - A Ludwig-Sengpiel
- KLB Gesundheitsforschung Lübeck GmbH, Sandstr. 18, 23552, Lübeck, Germany.
| | - G C Hupp
- Yale Center for Asthma and Airway Disease, Division of Pulmonary and Critical Care and Sleep Medicine, Yale School of Medicine, TAC 441, 300 Cedar Street, New Haven, CT, 06520, USA.
| | - V Backer
- Department of Respiratory Medicine, Respiratory Research Unit, Bispebjerg University Hospital, Bispebjerg bakke 23, DK-2400, Copenhagen, NV, Denmark.
| | - C Porsbjerg
- Department of Respiratory Medicine, Respiratory Research Unit, Bispebjerg University Hospital, Bispebjerg bakke 23, DK-2400, Copenhagen, NV, Denmark.
| | - P O Girodet
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, CIC 1401, F-33000, Bordeaux, France
| | - P Berger
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, CIC 1401, F-33000, Bordeaux, France.
| | - R Leigh
- Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - J N Kline
- Division of Pulmonary, C ritical Care, and Occupational Medicine, University of Iowa, W219B GH UIHC, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - M Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham & Birmingham VA Medical Center, 422 THT, 1900 University Blvd, Birmingham, AL, 35294, USA.
| | - W Calhoun
- 4.116 John Sealy Annex, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0568, USA.
| | - A Hussaini
- Parexel International, Shelton Simmons (MD), 3001 S Hanover St #7, Brooklyn, MD, 21225, USA.
| | - S Khatri
- Department of Pulmonary and Critical Care, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - P Chanez
- Department of Respiratory Diseases and CIC Nord AP-HM, UMR INSERM U1067 CNRS 7733, Aix-Marseille Université, Marseille, France.
| | - V S Susulic
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - E S Barnathan
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - M Curran
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - A M Das
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - C Brodmerkel
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - F Baribaud
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
| | - M J Loza
- Janssen Research & Development LLC, 1400 McKean Rd, Springhouse, PA, 19477, USA
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Raghu G, Martinez FJ, Brown KK, Costabel U, Cottin V, Wells AU, Lancaster L, Gibson KF, Haddad T, Agarwal P, Mack M, Dasgupta B, Nnane IP, Flavin SK, Barnathan ES. CC-chemokine ligand 2 inhibition in idiopathic pulmonary fibrosis: a phase 2 trial of carlumab. Eur Respir J 2015; 46:1740-50. [PMID: 26493793 DOI: 10.1183/13993003.01558-2014] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 07/12/2015] [Indexed: 11/05/2022]
Abstract
The objective of this study was to determine the safety and efficacy of carlumab in the treatment of idiopathic pulmonary fibrosis (IPF).A phase 2, randomised, double-blind placebo-controlled dose-ranging study was conducted in patients with IPF (n=126). Patients were randomised to carlumab (1 mg·kg(-1), 5 mg·kg(-1), or 15 mg·kg(-1)) or placebo every 4 weeks. The primary endpoint was the rate of percentage change in forced vital capacity (FVC). Secondary endpoints were time to disease progression, absolute change in FVC, relative change in diffusing capacity of the lung for carbon monoxide (DLCO), and St George's Respiratory Questionnaire (SGRQ) total score.Due to a pre-planned, unfavourable interim benefit-risk analysis, dosing was suspended. The rate of percentage change in FVC showed no treatment effect (placebo -0.582%, 1 mg·kg(-1) -0.533%, 5 mg·kg(-1) -0.799% and 15 mg·kg(-1) -0.470%; p=0.261). All active treatment groups showed a greater decline in FVC (1 mg·kg(-1) -290 mL, 5 mg·kg(-1) -370 mL and 15 mg·kg(-1) -320 mL) compared with placebo (-130 mL). No effect on disease progression, DLCO, infection rates or mortality was observed. SGRQ scores showed a nonsignificant trend toward worsening with active treatment. Unexpectedly, free CC-chemokine ligand 2 levels were elevated above baseline at both 24 and 52 weeks. A higher proportion of patients with one or more serious adverse events was observed in the 5 mg·kg(-1) group (53.1%) compared with 1 mg·kg(-1) (15.2%), 15 mg·kg(-1) (21.9%) and placebo (46.4%), although no unexpected serious adverse events were noted.Although dosing was stopped prematurely, it is unlikely that carlumab provides benefit to IPF patients.
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Affiliation(s)
- Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Ulrich Costabel
- Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Vincent Cottin
- National Reference Centre, Department of Respiratory Medicine, Claude Bernard Lyon 1 University, Hospices Civils de Lyon, Lyon, France
| | - Athol U Wells
- Royal Brompton Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Lisa Lancaster
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA
| | - Kevin F Gibson
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Michael Mack
- Janssen Research & Development LLC, Spring House, PA, USA
| | | | - Ivo P Nnane
- Janssen Research & Development LLC, Spring House, PA, USA
| | - Susan K Flavin
- Janssen Research & Development LLC, Spring House, PA, USA
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Judson MA, Mack M, Beaumont JL, Watt R, Barnathan ES, Victorson DE. Validation and important differences for the Sarcoidosis Assessment Tool. A new patient-reported outcome measure. Am J Respir Crit Care Med 2015; 191:786-95. [PMID: 25594886 DOI: 10.1164/rccm.201410-1785oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Patient-reported outcome (PRO) measures have been developed to measure symptoms and other aspects of health-related quality of life. OBJECTIVES The Sarcoidosis Assessment Tool (SAT), a sarcoidosis-specific PRO, was administered in a lung and skin sarcoidosis treatment trial. We explored SAT performance characteristics and correlation with standard clinical measurements to validate it as a useful clinical sarcoidosis-specific PRO. METHODS The SAT analyses focused on baseline and Week 16 assessments. Besides the SAT, participants underwent clinical and physician assessments plus additional PROs that were used as anchor variables and were compared with the SAT. Reliability was evaluated by using Cronbach α coefficient. Spearman correlation coefficients were used to evaluate the association between SAT scores with clinical and other PRO measures. Changes between assessments in the clinical and PRO "anchor" variables were classified as improved, stable, or worsened. Mean differences between adjacent categories of the known groups and mean changes from the ability to detect change analyses were reviewed for appropriate clinically important difference estimates. MEASUREMENTS AND MAIN RESULTS Results from 173 patients were analyzed. Each SAT module reflected appropriate anchor variables at baseline and in terms of change. The Cronbach α for each of these modules was at least 0.87. In addition, we successfully established a clinically important difference range for each SAT module. CONCLUSIONS We demonstrated that the SAT is a reliable and consistent sarcoidosis-specific PRO. It has excellent internal consistency and reliability. A range of clinically important differences has been established for the SAT modules. Clinical trial registered with www.clinicaltrials.gov (NCT 00955279).
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Affiliation(s)
- Marc A Judson
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Albany Medical College, Albany, New York
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Del Vecchio AM, Branigan PJ, Barnathan ES, Flavin SK, Silkoff PE, Turner RB. Utility of animal and in vivo experimental infection of humans with rhinoviruses in the development of therapeutic agents for viral exacerbations of asthma and chronic obstructive pulmonary disease. Pulm Pharmacol Ther 2014; 30:32-43. [PMID: 25445932 PMCID: PMC7110859 DOI: 10.1016/j.pupt.2014.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/24/2014] [Accepted: 10/29/2014] [Indexed: 12/16/2022]
Abstract
There is an association with acute viral infection of the respiratory tract and exacerbations of asthma and chronic obstructive pulmonary disease (COPD). Although these exacerbations are associated with several types of viruses, human rhinoviruses (HRVs) are associated with the vast majority of disease exacerbations. Due to the lack of an animal species that is naturally permissive for HRVs to use as a facile model system, and the limitations associated with animal models of asthma and COPD, studies of controlled experimental infection of humans with HRVs have been used and conducted safely for decades. This review discusses how these experimental infection studies with HRVs have provided a means of understanding the pathophysiology underlying virus-induced exacerbations of asthma and COPD with the goal of developing agents for their prevention and treatment.
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Affiliation(s)
- Alfred M Del Vecchio
- Janssen Research and Development, Immunology Clinical Research and Development, Welsh and McKean Roads, Spring House, PA 19477, USA
| | - Patrick J Branigan
- Janssen Research and Development, Immunology Clinical Research and Development, Welsh and McKean Roads, Spring House, PA 19477, USA
| | - Elliot S Barnathan
- Janssen Research and Development, Immunology Clinical Research and Development, Welsh and McKean Roads, Spring House, PA 19477, USA
| | - Susan K Flavin
- Janssen Research and Development, Immunology Clinical Research and Development, Welsh and McKean Roads, Spring House, PA 19477, USA
| | - Philip E Silkoff
- Janssen Research and Development, Immunology Clinical Research and Development, Welsh and McKean Roads, Spring House, PA 19477, USA.
| | - Ronald B Turner
- University of Virginia, School of Medicine, Charlottesville, VA 22908, USA
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Zhu J, Message SD, Qiu Y, Mallia P, Kebadze T, Contoli M, Ward CK, Barnathan ES, Mascelli MA, Kon OM, Papi A, Stanciu LA, Jeffery PK, Johnston SL. Airway inflammation and illness severity in response to experimental rhinovirus infection in asthma. Chest 2014; 145:1219-1229. [PMID: 24457412 PMCID: PMC4042510 DOI: 10.1378/chest.13-1567] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The nature of bronchial mucosal inflammation and its physiologic and clinical significance in rhinovirus-induced asthma exacerbations is unclear. We investigated bronchial mucosal inflammatory response and its association with physiologic and clinical outcomes in an experimental model of rhinovirus-induced asthma exacerbations. Methods: We used immunohistochemistry methods to detect phenotypes of inflammatory cells infiltrating the bronchial mucosa before and after experimental rhinovirus infection in 10 subjects with asthma and 15 normal subjects. Results: Compared with baseline, rhinovirus infection significantly increased the number of epithelial (P = .005) and subepithelial (P = .017) neutrophils in subjects with asthma only and subepithelial CD68+ macrophages in both subjects with asthma (P = .009) and normal subjects (P = .018) but more so in those with asthma (P = .021). Numbers of CD45+, CD68+, and CD20+ cells; neutrophils; and eosinophils at day 4 postinfection were positively associated with virus load (r = 0.50-0.72, P = .016-0.03). At acute infection in subjects with asthma, CD4+ cells correlated with chest symptom scores (r = 0.69, P = .029), the fall in the 10% fall in FEV1 (PC10) correlated with neutrophils (r = −0.89, P = .029), the PC10 correlated inversely with CD4+ (r = −0.67, P = .023) and CD8+ cells (r = −0.65, P = .03), the 20% fall in FEV1 was inversely associated with CD20+ cells (r = −0.65, P = .03), and higher epithelial CD8+ cell counts were significantly associated with a greater maximum fall in FEV1 (r = −0.72, P = .03), whereas higher subepithelial mast cell counts were significantly associated with a lower maximum percent fall in peak expiratory flow (r = 0.8, P = .024). Conclusions: In subjects with asthma, rhinovirus infection induces bronchial mucosal neutrophilia and more severe monocyte/macrophage infiltration than in normal subjects. Airway neutrophils, eosinophils, and T and B lymphocytes during infection are related to virus load and physiologic and clinical severity, whereas mast cells are related to greater lung function.
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Affiliation(s)
- Jie Zhu
- Department of Respiratory Medicine; National Heart and Lung Institute, Imperial College London, London, England
| | - Simon D Message
- Department of Respiratory Medicine; Imperial College Healthcare NHS Trust, London, England
| | - Yusheng Qiu
- National Heart and Lung Institute, Imperial College London, London, England
| | - Patrick Mallia
- Department of Respiratory Medicine; Imperial College Healthcare NHS Trust, London, England
| | | | - Marco Contoli
- Department of Respiratory Medicine; Imperial College Healthcare NHS Trust, London, England; Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | | | | | | | - Onn M Kon
- Imperial College Healthcare NHS Trust, London, England
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | | | - Peter K Jeffery
- National Heart and Lung Institute, Imperial College London, London, England
| | - Sebastian L Johnston
- Department of Respiratory Medicine; Imperial College Healthcare NHS Trust, London, England.
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Judson MA, Baughman RP, Costabel U, Drent M, Gibson KF, Raghu G, Shigemitsu H, Barney JB, Culver DA, Hamzeh NY, Wijsenbeek MS, Albera C, Huizar I, Agarwal P, Brodmerkel C, Watt R, Barnathan ES. Safety and efficacy of ustekinumab or golimumab in patients with chronic sarcoidosis. Eur Respir J 2014; 44:1296-307. [PMID: 25034562 DOI: 10.1183/09031936.00000914] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sarcoidosis is characterised by non-caseating granulomas that secrete pro-inflammatory cytokines, including interleukin (IL)-12, IL-23, and tumour necrosis factor (TNF)-α. Ustekinumab and golimumab are monoclonal antibodies that specifically inhibit IL-12/IL-23 and TNF-α, respectively. Patients with chronic pulmonary sarcoidosis (lung group) and/or skin sarcoidosis (skin group) received either 180 mg ustekinumab at week 0 followed by 90 mg every 8 weeks, 200 mg golimumab at week 0 followed by 100 mg every 4 weeks, or placebo. Patients underwent corticosteroid tapering between weeks 16 and 28. The primary end-point was week 16 change in percentage predicted forced vital capacity (ΔFVC % pred) in the lung group. Major secondary end-points were: week 28 for ΔFVC % pred, 6-min walking distance, St George's Respiratory Questionnaire (lung group), and Skin Physician Global Assessment response (skin group). At week 16, no significant differences were observed in ΔFVC % pred with ustekinumab (-0.15, p = 0.13) or golimumab (1.15, p = 0.54) compared with placebo (2.02). At week 28, there were no significant improvements in the major secondary end-points, although a nonsignificant numerically greater Skin Physician Global Assessment response was observed following golimumab treatment (53%) when compared with the placebo (30%). Serious adverse events were similar in all treatment groups. Although treatment was well tolerated, neither ustekinumab nor golimumab demonstrated efficacy in pulmonary sarcoidosis. However, trends towards improvement were observed with golimumab in some dermatological end-points.
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Affiliation(s)
- Marc A Judson
- Dept of Medicine, Albany Medical College, Albany, NY, USA
| | - Robert P Baughman
- Dept of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ulrich Costabel
- Ruhrlandklinik and University of Duisburg-Essen, Essen, Germany
| | - Marjolein Drent
- Dept of Interstitial Lung Diseases, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Kevin F Gibson
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Hidenobu Shigemitsu
- University of Southern California, Los Angeles, CA, USA Division of Pulmonary and Critical Care Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - Joseph B Barney
- Pulmonary and Critical Care Medicine, University of Alabama, Birmingham, AL, USA
| | - Daniel A Culver
- Pulmonary, Allergy and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Marlies S Wijsenbeek
- Dept of Pulmonary Disease, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Carlo Albera
- Dept of Pulmonary Medicine, Erasmus Medical Centre, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Isham Huizar
- Dept of Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Prasheen Agarwal
- Biostatistics, Janssen Research and Development, LLC, Spring House, PA, USA
| | - Carrie Brodmerkel
- Immunology Biomarkers, Janssen Research and Development, LLC, Spring House, PA, USA
| | - Rosemary Watt
- Immunology, Janssen Research and Development, LLC, Spring House, PA, USA
| | - Elliot S Barnathan
- Immunology, Janssen Research and Development, LLC, Spring House, PA, USA
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Barchuk W, Lambert J, Fuhr R, Jiang JZ, Bertelsen K, Fourie A, Liu X, Silkoff PE, Barnathan ES, Thurmond R. Effects of JNJ-40929837, a leukotriene A4 hydrolase inhibitor, in a bronchial allergen challenge model of asthma. Pulm Pharmacol Ther 2014; 29:15-23. [PMID: 25018015 DOI: 10.1016/j.pupt.2014.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/10/2014] [Accepted: 06/25/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED Leukotriene B4 (LTB4) is a chemotactic mediator implicated in the pathogenesis of asthma. JNJ-40929837 is an oral inhibitor of LTA4 hydrolase, which catalyzes LTB4 production. We evaluated the effects of JNJ-40929837 in a human bronchial allergen challenge (BAC) model. In this double-blind, 3-period crossover study, 22 patients with mild, atopic asthma were randomized to one of three treatments per period: 100 mg/day JNJ-40929837 for 6 days followed by 50 mg/day on day 7; 10 mg/day montelukast for 6 days; and matched placebo. The BAC was performed on day 6 of each treatment period. Primary outcome was BAC-induced late asthmatic response (LAR) measured by maximal percent reduction in forced expiratory volume (FEV1) in one second. Secondary outcomes included early asthmatic response (EAR) by maximal percent reduction in FEV1, EAR and LAR evaluated by area under the FEV1/time curve (AUC0-2, AUC3-10, respectively), change in baseline FEV1 after 5-day treatment, safety, and correlation of JNJ-40929837 to the divalent cation ionophore A23187-stimulated whole blood LTB4 levels and sputum basal LTB4 levels. No significant differences were observed in the primary or secondary FEV1 endpoints with JNJ-40929837 versus placebo. Compared with placebo (n = 17, LS mean = 27.7), there was no significant attenuation of the maximal percent reduction in the LAR FEV1 with JNJ-40929837 (n = 16, LS mean = 28.6, P = 0.63) but montelukast (n = 17, LS mean = 22.6, P = 0.01) significantly attenuated the LAR. JNJ-40929837 substantially inhibited LTB4 production in whole blood, decreased sputum LTB4 levels and was well-tolerated. The number of adverse events leading to study withdrawal was the same in JNJ-40929837 and placebo groups. In conclusion, JNJ-40929837 demonstrated target engagement in blood and sputum. No significant impact in response to allergen inhalation was observed with JNJ-40929837 versus placebo. REGISTRATION This study is registered at ClinicalTrials.gov: NCT01241422.
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Affiliation(s)
- W Barchuk
- Immunology, Janssen Research & Development, LLC, San Diego, CA, USA.
| | - J Lambert
- Early Phase Clinical Unit, PAREXEL International, Harrow, UK
| | - R Fuhr
- Early Phase Clinical Unit, PAREXEL International, Berlin, Germany
| | - J Z Jiang
- Biostatistics, Janssen Research & Development, LLC, San Diego, CA, USA
| | - K Bertelsen
- Clinical Pharmacology, Janssen Research & Development, LLC, Titusville, NJ, USA
| | - A Fourie
- Immunology, Janssen Research & Development, LLC, San Diego, CA, USA
| | - X Liu
- Immunology, Janssen Research & Development, LLC, San Diego, CA, USA
| | - P E Silkoff
- Immunology, Janssen Research & Development, LLC, Spring House, PA, USA
| | - E S Barnathan
- Immunology, Janssen Research & Development, LLC, Spring House, PA, USA
| | - R Thurmond
- Immunology, Janssen Research & Development, LLC, San Diego, CA, USA
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Judson MA, Baughman RP, Costabel U, Mack M, Barnathan ES. The potential additional benefit of infliximab in patients with chronic pulmonary sarcoidosis already receiving corticosteroids: a retrospective analysis from a randomized clinical trial. Respir Med 2013; 108:189-94. [PMID: 24361164 DOI: 10.1016/j.rmed.2013.11.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 11/26/2013] [Accepted: 11/30/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infliximab, a TNF-alpha antagonist, has shown efficacy in the treatment of sarcoidosis. Since corticosteroids inhibit TNF-alpha expression, we postulated that sarcoidosis patients receiving a sufficient corticosteroid dose may have an attenuated response to the addition of infliximab. METHODS We analyzed data from a previous randomized double blind prospective trial of infliximab versus placebo for chronic pulmonary sarcoidosis. The effect of the maintenance corticosteroid dose on the change in FVC % predicted between 0 and 24 weeks (ΔFVC%pred0-24) was analyzed in two ways. First, the mean ΔFVC%pred0-24 was calculated for the placebo and infliximab groups using three different daily prednisone equivalent dose thresholds: a) <10 mg versus ≥10 mg; b) <15 mg versus ≥15 mg; c) <20 mg versus ≥20 mg. Second, in both the placebo and infliximab groups, a correlation coefficient was calculated between the maintenance corticosteroid dose and ΔFVC%pred0-24. RESULTS Both the group that received infliximab and either a maintenance daily dose of <10 mg of prednisone and the group receiving ≥10 mg had a significant increase in FVC%pred0-24. However, both the groups that received infliximab and a corticosteroid dose of >15 mg of prednisone and ≥20 mg of prednisone did not demonstrate a significant ΔFVC%pred0-24. For the placebo group, there was no significant correlation between the corticosteroid dose and the ΔFVC%pred0-24. For the infliximab group, there was a significant correlation (p = 0.0097) between higher corticosteroid dose and less improvement in FVC%pred0-24. CONCLUSION Our results suggest that infliximab adds minimal potential benefit to corticosteroids for pulmonary sarcoidosis at doses above 15-20 mg/day of prednisone.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA.
| | | | - Ulrich Costabel
- Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Michael Mack
- Janssen Research & Development, LLC, Spring House, PA, USA
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Rennard SI, Flavin SK, Agarwal PK, Lo KH, Barnathan ES. Long-term safety study of infliximab in moderate-to-severe chronic obstructive pulmonary disease. Respir Med 2012; 107:424-32. [PMID: 23246078 DOI: 10.1016/j.rmed.2012.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/12/2012] [Accepted: 11/16/2012] [Indexed: 01/29/2023]
Abstract
RATIONALE There was an increased number of malignancies in infliximab-treated (5.7%) over placebo-treated (1.3%) patients in a 44-week, phase 2 clinical study of 234 patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). OBJECTIVES To collect malignancy and mortality data from completed clinical studies of infliximab in COPD treatment. METHODS The multicenter, observational Remicade Safety Under Long-Term Study in COPD (RESULTS COPD) collected malignancy and mortality data every six months for five years from patients who received ≥1 study-agent dose in a phase 2 study. Co-primary endpoints were the number of patients with malignancy and the number of deaths. Secondary endpoints included the number of patients with a malignancy according to malignancy type. RESULTS There was a gap period between the end of the phase 2 study and the initiation of RESULTS COPD, during which six malignancies and 14 deaths were reported spontaneously for the 107 (45.7%) of 234 patients with long-term safety information. Twenty-eight patients (overall 12.0%; placebo 10.4%, infliximab 12.7%) reported malignancies, including 12 patients during RESULTS COPD. Twenty-six patients (overall 11.1%; placebo 9.1%, infliximab 12.1%) died, including nine during RESULTS COPD. Lung cancer was the most common malignancy type (placebo n = 2; infliximab n = 10). CONCLUSIONS The greater proportion of malignancies observed with infliximab versus placebo in a phase 2 study diminished over the long-term follow-up. Due to the observational nature, limited patient participation, potential reporting bias from the interim spontaneous reporting period, and unblinding of all patients, more definitive conclusions cannot be drawn.
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Affiliation(s)
- Stephen I Rennard
- Division of Pulmonary, Critical Care, Sleep & Allergy, Internal Medicine, University of Nebraska Medical Center, 4111 Dewey Avenue, Omaha, NE 68198, USA.
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Loza MJ, Watt R, Baribaud F, Barnathan ES, Rennard SI. Systemic inflammatory profile and response to anti-tumor necrosis factor therapy in chronic obstructive pulmonary disease. Respir Res 2012; 13:12. [PMID: 22300528 PMCID: PMC3287122 DOI: 10.1186/1465-9921-13-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 02/02/2012] [Indexed: 01/05/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is characterized by progressive worsening of airflow limitation associated with abnormally inflamed airways in older smokers. Despite correlative evidence for a role for tumor necrosis factor-alpha in the pathogenesis of COPD, the anti-tumor necrosis factor-alpha, infliximab did not show clinical efficacy in a double-blind, placebo-controlled, phase II clinical trial. This study sought to evaluate the systemic inflammatory profile associated with COPD and to assess the impact of tumor necrosis factor neutralization on systemic inflammation. Methods Serum samples (n = 234) from the phase II trial were collected at baseline and after 24 weeks of placebo or infliximab. Additionally, baseline serum samples were obtained from an independent COPD cohort (n = 160) and 2 healthy control cohorts (n = 50; n = 109). Serum concentrations of a broad panel of inflammation-associated analytes were measured using a 92-analyte multiplex assay. Results Twenty-five proteins were significantly elevated and 2 were decreased in COPD, including highly elevated CD40 ligand, brain-derived neurotrophic factor, epidermal growth factor, acute-phase proteins, and neutrophil-associated proteins. This profile was largely independent of smoking status, age, and clinical phenotype. The majority of these associations of serum analytes with COPD are novel findings. Increased serum creatine kinase-muscle/brain and myoglobin correlated modestly with decreased forced expiratory volume at 1 second, suggesting cardiac involvement. Infliximab did not affect this systemic inflammatory profile. Conclusions A robust systemic inflammatory profile was associated with COPD. This profile was generally independent of disease severity. Because anti-tumor necrosis factor-alpha did not influence systemic inflammation, how to control the underlying pathology beyond symptom suppression remains unclear. Trial Registration ClinicalTrials.gov, No.: NCT00056264.
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Affiliation(s)
- Matthew J Loza
- Immunology Biomarkers, Janssen Research & Development, LLC, Malvern, PA, USA.
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Judson MA, Marchell RM, Mascelli M, Piantone A, Barnathan ES, Petty KJ, Chen D, Fan H, Grund H, Ma K, Baribaud F, Brodmerkel C. Molecular profiling and gene expression analysis in cutaneous sarcoidosis: the role of interleukin-12, interleukin-23, and the T-helper 17 pathway. J Am Acad Dermatol 2011; 66:901-10, 910.e1-2. [PMID: 21924794 DOI: 10.1016/j.jaad.2011.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/10/2011] [Accepted: 06/01/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cutaneous sarcoidosis (CS) skin provides relatively noninvasive access to granulomatous sarcoidosis tissue. OBJECTIVE We sought to explore the role of the T-helper (Th)1 and Th17 pathways in sarcoidosis. METHODS We used molecular profiling and gene expression analysis to analyze the Th1 and Th17 pathways and other immune-mediated pathways in CS. Molecular profiles were obtained from sarcoidosis skin lesions (lesional skin [LS]), unaffected skin from patients with CS (non-LS), and the skin of healthy control subjects. Whole blood was collected to compare the molecular profile of sarcoidosis skin lesions and whole blood. RESULTS Twenty participants were enrolled: 15 with active CS and 5 healthy volunteers. Microarray analyses comparing non-LS and healthy volunteer skin with LS showed several thousand genes differentially expressed (≥2-fold change false discovery rate, P < .01). Targeted selections of genes associated with Th1 and Th17 phenotypes showed a strong Th1 profile of sarcoidosis and expression of interleukin (IL)-23 and IL-23R with limited expression of other Th17 pathway genes. IL-21 and signal transducer and activator of transcription 3 (STAT3) were also dysregulated in skin and whole blood, providing additional evidence for involvement of the IL-12 pathway and potential activation of the Th17 pathway. LIMITATIONS Measurements were made at a single point in time and may not identify mechanisms that may be identified in patients followed up longitudinally. CONCLUSION These findings provide novel insight into the dysregulated pathways that may be involved in the pathogenesis of sarcoidosis.
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Affiliation(s)
- Marc A Judson
- Medical University of South Carolina, Charleston, South Carolina, USA.
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Prati F, Petronio S, Van Boven AJ, Tendera M, De Luca L, de Belder MA, Galassi AR, Imola F, Montalescot G, Peruga JZ, Barnathan ES, Ellis S, Savonitto S. Evaluation of Infarct-Related Coronary Artery Patency and Microcirculatory Function After Facilitated Percutaneous Primary Coronary Angioplasty. JACC Cardiovasc Interv 2010; 3:1284-91. [DOI: 10.1016/j.jcin.2010.08.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 08/04/2010] [Accepted: 08/20/2010] [Indexed: 10/18/2022]
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Sweiss NJ, Barnathan ES, Lo K, Judson MA, Baughman R. C-reactive protein predicts response to infliximab in patients with chronic sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2010; 27:49-56. [PMID: 21086905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND This study assessed the value of C-reactive protein as a predictor of disease severity and response to infliximab therapy in patients with chronic pulmonary sarcoidosis. DESIGN Sera were collected through week 52 from 138 patients with chronic pulmonary sarcoidosis who received placebo or infliximab in a randomized, double-blind, placebo-controlled study. We evaluated the response to therapy by baseline CRP using a dichotomous cutpoint (0.8 mg/dL) for the change from baseline in percent-predicted forced vital capacity (FVC), Saint George's Respiratory Questionnaire (SGRQ), 6-minute walk distance (6MWD), Borg's CR10 dyspnea score, and Physician Organ Assessment (POA). RESULTS CRP was elevated in 36% of patients at baseline, and was significantly reduced by infliximab by week 2. Among patients with elevated baseline CRP, infliximab-treated patients improved significantly compared with placebo-treated patients in percent-predicted FVC (+2.5 versus -2.6%), 6MWD (+8.0 versus -34.1), Borg's CR10 dyspnea score (pre-6MWD -0.8 versus +0.9, post-6MWD -1.1 versus +0.8), and POA (-3.1 versus -0.3). Patients with lower CRP levels at baseline did not show significant differences between the placebo and infliximab groups in most endpoints evaluated. CONCLUSIONS In chronic sarcoidosis patients, elevated CRP appears to identify a subset with more severe disease who may respond better to treatment with infliximab.
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Affiliation(s)
- N J Sweiss
- University of Chicago, Chicago, IL, USA.
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Montalescot G, Ellis SG, de Belder MA, Janssens L, Katz O, Pluta W, Ecollan P, Tendera M, van Boven AJ, Widimsky P, Andersen HR, Betriu A, Armstrong P, Brodie BR, Herrmann HC, Neumann FJ, Effron MB, Lu J, Barnathan ES, Topol EJ. Enoxaparin in Primary and Facilitated Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2010; 3:203-12. [DOI: 10.1016/j.jcin.2009.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 10/19/2009] [Accepted: 11/13/2009] [Indexed: 02/06/2023]
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Herrmann HC, Lu J, Brodie BR, Armstrong PW, Montalescot G, Betriu A, Neuman FJ, Effron MB, Barnathan ES, Topol EJ, Ellis SG. Benefit of Facilitated Percutaneous Coronary Intervention in High-Risk ST-Segment Elevation Myocardial Infarction Patients Presenting to Nonpercutaneous Coronary Intervention Hospitals. JACC Cardiovasc Interv 2009; 2:917-24. [DOI: 10.1016/j.jcin.2009.06.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 06/03/2009] [Accepted: 06/15/2009] [Indexed: 11/30/2022]
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Baughman RP, Shipley R, Desai S, Drent M, Judson MA, Costabel U, du Bois RM, Kavuru M, Schlenker-Herceg R, Flavin S, Lo KH, Barnathan ES. Changes in Chest Roentgenogram of Sarcoidosis Patients During a Clinical Trial of Infliximab Therapy. Chest 2009; 136:526-535. [DOI: 10.1378/chest.08-1876] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Mega JL, Braunwald E, Mohanavelu S, Burton P, Poulter R, Misselwitz F, Hricak V, Barnathan ES, Bordes P, Witkowski A, Markov V, Oppenheimer L, Gibson CM. Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial. Lancet 2009; 374:29-38. [PMID: 19539361 DOI: 10.1016/s0140-6736(09)60738-8] [Citation(s) in RCA: 489] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rivaroxaban is an oral direct factor Xa inhibitor that has been effective in prevention of venous thromboembolism in patients undergoing elective orthopaedic surgery. However, its use after acute coronary syndromes has not been investigated. In this setting, we assessed the safety and efficacy of rivaroxaban and aimed to select the most favourable dose and dosing regimen. METHODS In this double-blind, dose-escalation, phase II study, undertaken at 297 sites in 27 countries, 3491 patients stabilised after an acute coronary syndrome were stratified on the basis of investigator decision to use aspirin only (stratum 1, n=761) or aspirin plus a thienopyridine (stratum 2, n=2730). Participants were randomised within each strata and dose tier with a block randomisation method at 1:1:1 to receive either placebo or rivaroxaban (at doses 5-20 mg) given once daily or the same total daily dose given twice daily. The primary safety endpoint was clinically significant bleeding (TIMI major, TIMI minor, or requiring medical attention); the primary efficacy endpoint was death, myocardial infarction, stroke, or severe recurrent ischaemia requiring revascularisation during 6 months. Safety analyses included all participants who received at least one dose of study drug; efficacy analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00402597. FINDINGS Three patients in stratum 1 and 26 in stratum 2 never received the study drug. The risk of clinically significant bleeding with rivaroxaban versus placebo increased in a dose-dependent manner (hazard ratios [HRs] 2.21 [95% CI 1.25-3.91] for 5 mg, 3.35 [2.31-4.87] for 10 mg, 3.60 [2.32-5.58] for 15 mg, and 5.06 [3.45-7.42] for 20 mg doses; p<0.0001). Rates of the primary efficacy endpoint were 5.6% (126/2331) for rivaroxaban versus 7.0% (79/1160) for placebo (HR 0.79 [0.60-1.05], p=0.10). Rivaroxaban reduced the main secondary efficacy endpoint of death, myocardial infarction, or stroke compared with placebo (87/2331 [3.9%] vs 62/1160 [5.5%]; HR 0.69, [95% CI 0.50-0.96], p=0.0270). The most common adverse event in both groups was chest pain (248/2309 [10.7%] vs 118/1153 [10.2%]). INTERPRETATION The use of an oral factor Xa inhibitor in patients stabilised after an acute coronary syndrome increases bleeding in a dose-dependent manner and might reduce major ischaemic outcomes. On the basis of these observations, a phase III study of low-dose rivaroxaban as adjunctive therapy in these patients is underway. FUNDING Johnson & Johnson Pharmaceutical Research & Development and Bayer Healthcare AG.
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Affiliation(s)
- J L Mega
- TIMI Study Group, Boston, MA, USA.
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